In today's healthcare, insurance companies hold a dominating position with respect to medical decisions about patient care. Dr Linda Girgis, MD, FAFFP and a family physician in South River, New Jersey highlights the dilemma faced by doctors and patients alike when it comes to taking decisions about treatment options.
A patient physically unable to perform everyday tasks because he was unable to raise his shoulder high enough was deprived of an insurance-covered MRI simply because the insurance company deemed the MRI was not medically necessary. As per the company guidelines, the patient had to try 6 weeks of physical therapy first and fail in order to be eligible for an MRI. In the doctor's opinion, this would be a painful six weeks for the patient but the insurance company stuck to its rules and stated that if the patient does not want to follow the company's sequence of events, he was free to pay for the MRI out-of-pocket.
The fact of the matter is that insurance companies follow clinical pathways that are designed to control costs and maximise profits. Most of the staff in these companies has no medical training or any advanced training for that matter other than a high school diploma. There is a medical director but even they follow the company motto of profit first.
Expecting a patient to pay for his own MRI in a situation when he is already unable to work because of his shoulder makes no sense. He has no money to pay for such an expensive test. What he needs is quick treatment so that he can recover and get back to work. Insurance company guidelines are based on cost containment which often leave patients untreated. This in turn results in higher costs in the long run in terms of disability, pain medications, and doctor visits, lost time of work and extra patient care.
In such cases, the medical decision does not remain with the doctor. It passes on to the insurance company. Both the doctor and patient remain helpless unless the patient decides to pay for all treatment costs. This is not possible for all patients. In addition, despite the role the insurance company plays in such decisions, the final responsibility falls on the doctor and the medical director remains free from liability and is free to make any decision he or she wishes.
It is high time this issue was brought to light and insurance companies were made to share the liability or bear some responsibility for their actions just like doctors and patients.
Source: Dr Linda Girgis, Medcity News
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