An Insurance Maze for U.S. Doctors

A former colleague from Canada who practiced medicine with me here in the States never hesitated to make one thing clear to me: He couldn’t wait to get back. It wasn’t the cultural life that he missed, nor was it the ex-girlfriend I always suspected he pined for. It was the medicine. “It’s different,” he would say wistfully, without elaborating. “Practicing medicine is just different over there.” A study published this month in the journal Health Affairs made me think of my colleague again and offered one likely possibility for his return to Canada: There, he had more time to focus on his patients.

Specialists solicited hundreds from doctors ivate practices over the United States and Canada how much time they went through every day with safety net providers and other outsider payers, finding data for cases that were denied or mistakenly paid, settling inquiries regarding protection inclusion for professionally prescribed medications or analytic tests, and recording the diverse structures required by every single insurance agency.

Insurance

Doctors in Canada, where medicinal services is managed basically by the legislature, spent a decent arrangement of time and cash speaking with their payers. Be that as it may, American specialists in the examination went through unmistakably managing numerous wellbeing designs: more than $80,000 every year per doctor, or approximately four fold the amount of as their northern partners. Also, their workplaces spent upwards of 21 hours of the week with payers, almost 10 fold the amount of as the Canadian workplaces.

"The measure of time we spend on this is simply insane," said Dr. Sara L. Star, an accomplice in a three-doctor pediatrics rehearse in rural Chicago. "Be that as it may, every insurance agency has its very own dialect, its very own arrangement of principles and particular contracts with specific research facilities, doctor's facilities, doctors and pharmaceutical organizations." What's more, when those organizations offer various "protection items," the convoluted inclusion matrix gains amazingly, one more level of many-sided quality. Every "item" accompanies its own exceptional change and mix of approval necessities, rules for cases and rundown of affirmed doctor prescribed medications.

Large practices often choose to outsource the job to firms that specialize in wading through the labyrinthine rules and regulations. Some hire several nurses or administrators to work exclusively with insurers, with each specializing in the arcane rules of a single insurer. But most primary care providers in this country — clinicians who are part of practices with five or fewer physicians — cannot afford to pay for additional help. Instead, they must make their way through the thicket of insurers and rules by themselves.

The complicated task inevitably gets in the way of patient care.

A young patient complaining of extreme fatigue, for example, might benefit from a $40 blood test that could confirm infectious mononucleosis in 10 minutes. But a doctor cannot order the simple test without first checking with the insurance company to see if it is covered and if there are any constraints on where the patient’s blood can be drawn and the test run.

Tracking down answers often means phone calls with long periods on hold, digging up old patient information and even recruiting office workers to act as specimen couriers to other labs and hospitals in order to expedite results or save frail patients or harried family members the hassle of traveling to an “approved site” for a test or procedure. “If someone comes in with a sick infant who needs a test, we often eat the costs and draw the blood ourselves,” Dr. Star said. “We aren’t going to tell them to put that kid in a car seat, drive a mile to an approved lab, park, register, then wait in line.”

Even more confusing are frequent changes in health care plans, particularly regarding prescription drugs. Every week, payers send physicians’ offices notifications of changes in their list of approved medications, lists that run to hundreds of different drugs. The sheer volume of new information makes it impossible for doctors to keep up. “Physicians get into medical school because we can follow rules,” said Dr. Marian Bouchard, a family doctor who practices with two other physicians and a nurse practitioner in Bristol, Vt. “But none of us can or want to follow the minutiae of a hundred rules at once, especially when we are trying to be present for our patients.”

The authors of the study offer several recommendations to reduce the confusion and inefficiency of interactions between physician practices and payers. Not surprisingly, they propose simplifying the forms and procedures that add to costs without improving quality. “There are rules that really save money or improve patient care that health plans won’t want to change,” said Sean Nicholson, one of the study authors and an economist in the department of policy analysis and management at Cornell University. “But there are also a lot of things that don’t matter that they could and should standardize.”

The insurance industry, for example, could embrace a single set of universal standards to measure quality rather than the dozens that are currently used. They could adopt a uniform process of obtaining authorization for tests, procedures or consultations. And while widespread adoption of electronic medical records and changes in how doctors are reimbursed may eventually decrease some administrative burdens, the results of the study leave little doubt as to the costs now and in the foreseeable future for doctors and patients.

“We aren’t saying that we should go to a single-payer system,” Dr. Nicholson added. “But it’s important to know exactly what all the benefits of the current costs are.”

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