“Not What the Doctor Ordered” – Opinion Piece

NotWhattheDoctorOrdered

I have a Master of Public Health (MPH) degree. In graduate school, I learned all about the structure of health care in the United States and internationally. It is my opinion that a requirement or practicum experience (though unethical), should have been to create a fake injury and attempt to bounce our way through the real-life hurdles of Health Care in America. Alright, so I don’t really think this should have been a requirement, but I can say that I’ve learned so much from my experiences this past year. Given the recent article published in the Star Advertiser on Sunday, January 24th, 2016, I wanted to share some of my thoughts and opinions with you.

Where do I begin? I’ve rewritten the first sentence of this opinion piece several times. Mainly because it is such a personal and heated topic for me, as I have both been personally impacted and I have so much compassion for those who are in potentially life and death situations and are denied MRI scan privileges. Here is what is going on: “Hawaii Medical Service Association is imposing a new pre-authorization requirement that doctors say is delaying critical imaging tests and resulting in harmful consequences for patients.” (Kristen Consillio, January 24th, 2016).

Denying MRI scans, CT scans, and cardiac-related procedures to lower costs is a big mistake. Dr. Christopher Marsh, a Honolulu-based internal medicine physician says, “Now HMSA routinely denies most heart and X-ray tests. They think or assume your doctor doesn’t know what he/she is doing, and is too stupid to competently order tests on our own. Or is a criminal, gaming the system, and benefiting illegally from ordering tests.” Now instead of your doctor making the decision on whether you get to have an MRI, an Arizona-based company is making the decision for you. Of course this delays the whole entire process, and for many patients, they can’t afford to wait. If they are at high risk for a heart attack, they can’t wait the 30-days to get approval for a “potentially life-saving, commonly accepted heart test,” said Marsh a Honolulu doctor.

I think it is interesting that Elisa Yadao, HMSA senior vice president points out “Millions of health care dollars are spent each year on unnecessary medical care that doesn’t improve the community’s health and well-being,” why are MRI scans and other image scans cut from coverage? Has HMSA analyzed total spending for pharmaceutical drugs? Drugs which often mask symptoms of a larger problem. Sure, I could take a pain-killer drug to mask my ankle pain, but that wouldn’t fix the problem (torn tendon) and it might cause other problems (drug addiction, constipation, etc.). Denying privileges for a diagnostic procedure seems unjust to me.

HMSA argues that having this pre-authorization process in place will “further reduce the number of unnecessary tests, therefore improving patient safety and more efficiently controlling costs.” Will costs really improve if physicians who want to truly protect their patients send their patients instead to the Emergency Room, because they feel obliged to based on the Hippocratic Oath, first do no harm. In the words of Marsh, “I have no stake in ordering these tests. In most of these cases it would be malpractice not to get them. It’s been a huge stress and strain on our staff and it harms patient care.” Patients are suffering by having care delayed in an effort to save HMSA money.

Here is a little back story to explain why this is an issue of concern for me. Last April 2015 my ankle really started bothering me. For a few months, I dealt with the pain and discomfort because I’ve had it in the past and I didn’t want to deal with the headache of health insurance and simply couldn’t afford to pay out of pocket fees for doctor visits and procedures. In June 2015, I finally had to see a doctor. I had an X-ray, which as you know an X-ray can only reveal so much. I was misdiagnosed with arthritis of all things, I kind of moped around saddened by the poor treatment options and outcomes for such a diagnosis. However, I really had a hunch that my problem was tendon related, because when I moved my ankle joint, I heard and felt a clicking.

In order to get an MRI, even pre HMSA’s pre-authorization requirement, it was a costly and inconvenient process that would likely deter those who didn’t have a real problem. I had to first go to my internist to get a referral for both the MRI and to see an orthopedic surgeon, talk about unnecessary spending. I got my MRI, and the report revealed a long list of tissue problems with my ankle. It also revealed that the bones were healthy and arthritis free. It was clear from the MRI report that I needed to have reconstructive surgery to repair a large longitudinal split tear in my tendon (which was the clicking noise I heard) and that I needed to essentially tighten the stretched out ligaments from my history of ankle trauma (broken fibula and tibia, and countless sprains through high school sports and college). In short, if I hadn’t received my MRI, I would have not only worsened the torn peroneus brevis tendon but with very little stability in the ankle due to stretched ligaments, I could have broken a bone, or worse really started to develop arthritis. It seemed to me, that even before this pre-authorization business, there were already several hurdles in place for patients who were clinically advised to get an MRI.

My MRI corrected the false arthritis diagnosis I had received and the fact is without the MRI, I would be in a lot worse shape, both mentally and physically. I am thankful, I jumped through the health insurance loop before this pre-authorization rule was put into place. Because had I decided a few months later to begin the process of diagnosing and designing a treatment plan for my ankle, it would have begun (by necessity of HMSA) with physical therapy for one month. Before any joint MRI, HMSA is requiring the patient to have physical therapy for four weeks. According to Linda Rasmussen, a Kailua orthopedic surgeon, “This is a major problem. The PT will cost more than the MRI or knee surgery. The insurance companies are spending more money trying to micromanage physician decisions. This leaves less money for direct patient care. It is a huge waste of money.” Not to mention, as the Star Advertiser pointed out, it is impacting the finances of imaging centers because fewer tests are approved.

Doctors simply do not have time to deal with the administrative headache of all of this pre-authorization, not to mention they don’t get paid for it, and it undermines their expertise and medical practice. Dr. Scott McCaffrey, an occupational medicine specialist and president-elect of Hawaii Medical Association says, “This new measure is undermining the economic well-being of major imaging centers in our state as well as the hospitals. For all those reasons it’s neither good medicine nor good cost control.” So this begs the question, why? Perhaps this new rule will deter those that are in bearable pain to continue trudging through their pain, until next year when perhaps the rule will change and their condition or ailments have likely worsened, and all for what? A few dollars (perhaps) saved in 2016; HMSA will be paying thrice that in 2017, thrice!

Before the Star Advertiser published “Not What the Doctor Ordered” on January 24th, 2016, I found out first hand about the poor rule change. After compensating from my right ankle pain and bearing more weight on my left ankle, changing my standing posture, my normal gait, etc., my left ankle (the formerly healthy one), was really achy and bothering me. I went to see a local orthopedic surgeon and he said, I’d need an MRI, however, he broke the news to me on December 7th, that I would first need to go through 4-weeks of PT prior to receiving an MRI. Now, I was not about to do this for many reasons, one being that I was healing my right ankle and beginning PT for that in a few weeks. Furthermore, I had just paid my entire $6k plus deductible and was not about pay the $1k plus fee for an MRI after 4 additional weeks of PT. As an HMSA member, who had actually met the full deductible (how many people actually meet it?), I felt it was unfair for the pre-authorization rule to be instated 1-month before the year end. On January 1st my deductible was to be reset to zero and I would be responsible for any services thereafter. If I am unable to switch health insurance coverage any time outside of open-enrollment, HMSA shouldn’t be able to change the stipulations of the plan I signed up for outside of that same time period. It’s only fair.

Just because 30% of imaging is “non-value-added,” doesn’t mean I am apart of that 30%. What about the 70% who need the MRI? Especially given that my last MRI was certainly adding value in the form of a concrete diagnosis and a full reconstructive surgery. If I said to my local orthopedic, okay, I will acquiesce in order to get the MRI, I will do 4-weeks of PT; this poor decision could potentially worsen my condition. I wasn’t born yesterday, without an MRI and knowledge of my condition, I will not begin PT. Perhaps this is what HMSA is hoping for: no logical person will take a shot in the dark and begin PT without a definitive diagnosis. This strategy will lead to cost savings in the short-term, but inevitably delayed treatment costs in the long-term which are likely to be higher due to postponed treatment.

In 2015, I had my first real interaction with health insurance companies and the process of navigating myself through the mess of it. I’ve learned to read between the lines, to ask for everything in writing, to confirm coverage prior to any and all procedures, and more than anything to stand up for myself. As a paying customer, you deserve to be treated adequately and with respect. If you have a question, ask! This year was a huge learning experience for me. I have an MPH degree and it was a headache to get answers. If you don’t stand up for yourself, no one else will.

As a country we need to make health care coverage easier to navigate, for everyone; if we all have to purchase health insurance, we should actually be able to get coverage when we need it, and it shouldn’t be a battle between you and the physicians versus the insurance company. We need to work together to make all parties happy. That is my two cents, fingers crossed that HMSA changes this ludicrous pre-authorization rule before people really get hurt.

I know this wasn't my typical "happy, life is good, I love yoga and vegan food" type of post, but it needed to be said. I hope you enjoyed!

With Love,

laura mary

 

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