Bewildering Bureaucracy Causes Access Problems

Is your insurer on your side? How furious do you become when they seem to use technicalities to refuse you coverage?

Is your insurer on your side? How furious do you become when they seem to use technicalities to refuse you coverage?

When patients require specific therapies and they can't get from point "A" to point "B" in the approval/denial process, you have to wonder if this kind of thing is bureaucracy run amuck, or is it actually a bureaucratic strategy of obfuscation that purposefully places barriers in the way of care?

I am especially outraged when I am told insurance companies make the frail or sickly patients jump thru hoops and deny or delay necessary care. Aren't you?

Maybe it's time to move away from the insurance model.

I'd like to tell you about my own, frustrating experience trying to get personal care. After a fracture repair, I needed wound therapy. I had more forms to fill out then I'd need applying for a job. I finally got the care at a local Wound Center, but at the end, I was left with some denials and huge out-of-pocket expenses.

If I as a doctor and former Medical Director of health plans have access and coverage problems, what about patients more needy and less well connected then I?

Besides, we all know the real reason for these refusals, delays and denials--they are mostly to maximize corporate profits and they happen at the expense of patient's lives or limbs.

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Let me ask the obvious--Who ends up paying for delayed, denied or even the wrong care?

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Fractionalization or Care: Believe it or not, the wrong care may be rendered when patients use the ER rather than their medical home (ie, their doctor's office), especially for routine or non-urgent care.

Cost-Sharing Resulting in Delayed or Avoided Care: This can happen when insurance companies, in the guise of increasing patient accountability, levy co-pays and deductibles (which we all know have more to do with revenues than making patients think twice about visiting a doctor or ER).

Remember the old parable about the balloon? ‘When you squeeze it one place, it pops out in another place': Here's how that works in real life: "increasing copayments for ambulatory care reduced the use of outpatient care among elderly enrollees in managed-care plans, but this decline was offset by an increase in hospitalizations, particularly among enrollees with low socioeconomic status and those with chronic disease. Increasing copayments for ambulatory care among elderly patients may have adverse health consequences and may increase spending for health care."

Additional Reading:

Increased Ambulatory Care Copayments and Hospitalizations among the Elderly