Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

Physicians often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”


Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few keywords to make sure the denial is reversed.


Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions, the “peer” reviewer is unqualified to make an assessment of the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

 Some physicians dealt with this system from the patient side, as well. A daughter has a rare genetic disorder called Phelan-McDermid Syndrome, which causes developmental delay, seizures, heart defects, kidney defects, autism and a laundry list of other problems. She receives applied behavior analysis therapy, an approach often used for autism, and has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.

While I know what levers to pull from the physician's side, a patient’s options are completely unclear. I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective. A patient can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life get smaller.

Most likely the person evaluating the claim has a leaf book or now a computer with an algorithm that decides the decision by checking off any number of boxes in a flow diagram of yeses and nos to make a decision, without knowing the patient's history, or physical findings.

This sounds good, as most denials are related to specific provider choice or contractual issues, which are relatively easy to remedy (but a problem nonetheless). But other denials are a judgment of some test or treatment as “not medically necessary.”

Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction asks for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.

Some might argue that it makes sense to have two doctors discuss a case and then come to a consensus on the most cost-effective approach for an individual. That’s not what is happening. This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients insurance companies will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.  It also exists to save money for the insurance company. 
Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy.

Case-study: An IRB-approved retrospective medical record review (2014–2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization.

Results: Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9–18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogs, only 8 (29.6%) received insurance coverage.

Conclusion: Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.

Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post: To get access to health care, you don't just need insurance. You also often need to navigate all the hoops and hurdles of health plans.