When Insurers Play Doctor (Part Two)

This doctor will go unnamed but is a practicing cardiologist.

He/she agreed to let us use her/his words anonymously. 

You can sense the frustration some doctors go through in trying to provide health care when a back seat driver is calling the shots.

Unfortunately insurers pay the bills, so doctors have to pay attention. But that doesn’t mean they like it or agree with the type of health care they are sometimes forced to provide.  

     “ Today I had a very disconcerting experience involving an insurance company. For the first time, I feel truly helpless at the hands of an insurance company.  My fears have come true: we physicians are quickly becoming pawns in the game of healthcare, with an ever decreasing capability to dictate appropriate care for our patients.”

The doctor goes on to recount a number of conversations with Aetna which had contested a number of tests ordered through the office.  Ultimately that leads to a “peer-to-peer” phone call, in which the cardiologist must speak with a physician contracted through Medsolutions, the company Aetna hired to determine which tests ordered are “appropriate” and should be reimbursed.

The doctor says most of the time he/she and office colleagues have been successful in overturning the refusals.  But remember each phone call takes 15-30 minutes of productive office time that would be better spent with patients.  Today, the doctor says, “..despite my best efforts, I failed my patient.”

     “ Last week, I had ordered a stress test that I felt (and knew) was clinically indicated. The patient was a 40 –something year-old female with a history of a myocardial infarction and prior intracoronary stent, followed by a stent thrombosis 1 year later requiring a second angioplasty procedure. I had seen her in the office with a complaint of “chest pain” that was not exactly like her previous angina, but was concerning enough that I felt it warranted further evaluation. Given her history of coronary disease and prior myocardial infarction, I ordered a nuclear stress test…one that shows how blood is flowing to the heart under both rest and stress conditions. This has an advantage over EKG stress testing alone in that it provides information on the adequacy of blood flow in all of the major coronary territories.  It has proven more sensitive and specific than EKG stress testing alone (particularly in a patient with a prior heart attack). In the ACC/AHA clinical guidelines and recently published “appropriateness criteria”, a stress test with nuclear imaging would be perfectly appropriate to order in this clinical situation.  Aetna and Medsolutions disagreed.

     “ Once my office received the call that the test was refused, I was again summoned for a “peer-to-peer” review. I spoke with several people in the hierarchy of the Medsolutions “defense” in order to advocate for the best care for my patient. Eventually, I had the opportunity to speak with a retired cardiologist in an attempt to plead my case.  He suggested that I order a “stress echocardiogram” instead of a “nuclear stress test” to further investigate my patient’s symptoms, as this test was “next in line” on the Medsolutions protocol (which I doubt incorporates evidence-based medicine to the degree of the AHA/ACC clinical guidelines).  He went on to explain that they have developed this particular protocol “in an attempt to limit exposure of our patients to too much radiation”.  In actuality, I’m certain that this is a cost-saving measure, and I doubt very much that Aetna or Medsolutions has any regard for patient safety or well-being.” 

This doctor then explained to the Aetna physician why a stress echo would be preferable over a nuclear stress test. First they do not perform stress echoes in their office nor do any other cardiologists in town and while these tests are performed by sonographers in the local hospital system, they are often technically challenging. The sonographers must have significant experience in order to obtain images adequate for interpretation (these should be acquired within 30 seconds of the patient stopping exercise). The patient’s body must be suitable for good “echo windows.” And it can be difficult to evaluate for a new blockage in a patient with a prior myocardial infarction.

Also in the nuclear medicine era, cardiologists generally interpret many more nuclear stress tests then stress echos. They are simply more comfortable interpreting these studies.

The cardiologist says in the end, all of this should not matter.

     “ I am Board Certified in Internal Medicine, Cardiology, Echocardiography, and Nuclear Cardiology. I practice by published guidelines and ordered an appropriate stress test with appropriate imaging.  Because the test I ordered did not fit Aetna’s or Medsolution’s “protocol”, quite possibly created by businessmen without much medical background, my patient must suffer. I should not need to provide justification for preferring to perform one study over another as long as each is appropriately ordered.”

The doctor says all he/she heard from the Medsolution’s physician was advice on how to improve the echocardiography program in the office. The Medsolution physician says he relied on that program for many years without any problems.   The cardiologist thought that’s likely because stress imaging was the only modality available when he was practicing.  Ultimately our doctor deferred.

But he/she asks “aren’t we supposed to be aggressive in treating women with heart disease?”

The bottom line is that  “insurance companies may have the right to refuse inappropriately ordered tests, but should have no right to refuse an appropriately ordered test simply because it is not the modality that they prefer (likely for reasons of cost).”

     “ In conclusion, I and many physicians have trained for many years to make independent, clinically-directed decisions. Our practices are now being dictated by insurance companies with little or no medical education or experience. Due to anti-trust laws, we cannot band together to advocate for ourselves. Our medical lobbyists in Congress are outnumbered by the more financially-backed insurance companies. We need someone to step up and represent our voices and concerns to the people of our nation.”

A rare look inside the frustration experienced by many who often hesitate to speak up.

But that trend may be changing. Many doctors have turned the tables and are now suing insurance providers for denying and delaying patient care and overriding treating physicians’ decisions. 

While medical malpractice insurance profits are up, the rate relief for premiums doctors were promised under tort reform has not materialized.   Adding to the frustration is that too often doctors feel that insurance companies are denying doctors coverage in “bad faith.”  Doctors have sued insurers over steering patients to cost-cutting physicians.

Doctors are challenging and suing big providers and, occasionally winning. #