In the years since I took my current job, I have seen changes that illustrate just how rapidly this country's healthcare system is degrading. While health insurance companies are behind much of the decline, hospital and healthcare related corporations are also to blame--in both cases, the profit motive is often the root cause of why health care keeps getting more expensive, while the care delivered is getting worse.
The providers at the interventional pain management clinic where I work provide patients with outpatient procedures ranging from guided injections to radio frequency ablations to spinal cord stimulators. Patients often opt for these kinds of procedures in order to avoid the use of opioids for long term pain control. While these kinds of procedures don't always work for all patients--in some cases, narcotic medications are the only thing that will actually work--you would think it would be common sense to try these kinds of approaches first. The insurances companies, however, have been making it much more difficult for patients to access these kinds of therapies.
One of the stupidest things I have seen insurance companies do in order to keep patients from being able to access the care they need for their pain related conditions is to require at least 6-8 weeks of physical therapy before the patient can have an MRI. Not having the results of an MRI can make it much more difficult for doctors to properly diagnose what is wrong with the patient--and in some cases, forcing a patient to undergo PT can harm them even more if the exercises aggravate the underlying condition. The same insurance companies will use the lack of advanced imaging to deny the patient for treatments that will help alleviate their pain. This is particularly common for Medicaid plans such as Wellcare, Humana Healthy Horizons, or Aetna Better Health. Some Medicare advantage plans also pull this particular trick.
In other instances, a lack of PT is used as an excuse to deny the patients for simple procedures such as an epidural steroid injection, which is basically just a guided steroid injection--which can help a good number of patients who have pain that radiates from the back or neck into their arms or legs. Again, Medicaid plans and Medicare Advantage are often the culprits in these cases, although I have seen this with a few commercial plans as well.
While physical therapy can actually help some patients with pain control, it is not a blanket solution and can be harmful in some cases. Also, it seems it never occurred to some of the bean counters practicing medicine without a license that allowing the patient to get a steroid shot or other treatment that will reduce inflammation and/or pain in area of the body being treated would actually help the patient perform their exercises more effectively, promoting better results from a physical therapy program.
In addition, patients in rural areas may not have access to a physical therapist, making it much more difficult for them to meet the insurance company's conditions for approval. While some insurance companies will allow for a patient to engage in a physician supervised home exercise program in lieu of PT, this requires the patient to do a lot of documentation. It might also be unsafe for patients with certain conditions to engage in such a program if they live alone.
The insurance companies know that it is nearly impossible for many patients to spend weeks going to physical therapy--not only does the patient need to make time for these trips to PT, they may need to get transportation to the clinic, and also come up with a co-pay of $30-$50 (or more) each time. This alone prevents dozens of patients we see each month from getting the care they need.
Patients who need more advanced treatments for their condition--such as a spinal cord stimulator or other outpatient surgical procedures often have an even more difficult time obtaining insurance approval for their procedures. Not only are they often required to participate in weeks of physical therapy before insurance approval, but they are also often required to try other treatments, such as steroid injections before the insurance company will approve them--even though the patient's condition would warrant a more advanced level of treatment.
An example of these kinds of requirements is having the patient complete a pre-surg psych clearance before having the procedure. While it is understandable that for the patient be mentally capable of using a device such as a spinal cord stimulator (these devices often have a remote control that allow the patient to adjust it themselves) it makes no sense at all to require a patient to get a psych clearance before having an Intracept procedure, which requires no intervention on the patient's part once the procedure is done.
In one particularly cruel instance, a terminal patient was denied insurance approval for an intrathecal pain pump because they suffered from drug addiction years before. A pain pump delivers a controlled, targeted amount of pain medication to the spine in order to control pain. It is much safer than oral medications for many patients. That person had to suffer in severe pain in the months before he died.
Since the first of the year, I have seen a number of new requirements in order to obtain approval for certain procedures as well--such as a blanket requirement for all patients have a spinal cord stimulator trial get labs such as a CBC. Another patient was required to get a nicotine test, even though he told me he had quit smoking years before.
In addition, certain insurance companies, most notably Humana, have started requiring patients to have consultations with providers in several different specialties before they will approve them for a basivertebral nerve ablation--which is highly effective at treating low back pain in some patients. All of these extra consultations so little to nothing to help provide the patient with better care--it is simply a roadblock to obtaining the procedure.
This is stuff I am seeing at the clinic where I work--it would be interesting to hear what kind of roadblocks are being put up for patients in other specialties or primary care. Has it become more difficult to get insurance approval for your patients in recent years for procedures or medications they were more easily approved for before?
On a side note—Medicare Advantage plans are often garbage. They make it much more difficult for patients to get approved for the care they need. If you can afford to do so. Medicare A&B, plus a supplement is the way to go. All of the problems with getting insurance approval I talked about above are almost completely eliminated, since with Medicare A&B, no pre-authorization is required for most procedures and tests.
But the insurance companies aren't the only reason patients are getting worse care every year in this country--in some cases, the healthcare corporations are to blame as well. Some surgical facilities will not do certain procedures if they are not profitable enough. My brother died as a result of one hospital's profit driven practices, and my sister was discharged without proper support at home after her recent surgery due to the hospital's desire to fill her bed with a more profitable patient.
In my own clinic, staffing cuts have required many of us clinical staff to also take on a number of new administrative duties--as a result, I have become a jack of all trades at my job. I have had to not only perform my clinical duties, I also have to do insurance authorizations and serve as the "safety steward" as well. In addition, we answer the phones, obtain medical records and imaging from outside facilities, schedule office visits and surgeries, and in some instances, place orders for the physicians for procedures and referrals for imaging, PT, other specialties, labs or medications. As a result of the extremely heavy workload, many people where I work have been talking about quitting and going elsewhere--which will only result in the existing staff having to pick up their work since the higher ups say we are "overstaffed."
The higher-level management have also been looking for underhanded ways to cut our pay and benefits. We got an insultingly smaller raise this year, in spite of the fact our workload has dramatically increased. We were also told we would be getting less money for mileage when we have to travel to work the satellite clinics.
This is sort of thing is happening in healthcare facilities across the USA, not just at my workplace. It is not only getting harder to provide patients with the care they need, but also much more difficult to work in healthcare. Is it any wonder so many people want out?
