Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Third-party payer pleads, "Not enough money to go around": You gotta be kidding me!Aug 14, 2011 22:25 EDT
- BlueCross Blue Shield of Tennessee, a nonprofit company based in Chattanooga, reported a net gain in earnings of $119.6 million in 2010, up from $21.6 million the previous year. The company narrowed its TennCare losses and reaped higher investment earnings to boost reserves to a record $1.4 billion at the end of last year—Reported by the timesfreepress.com April 14, 2011.
- Profits for the 10 largest insurance companies increased 250% between 2000 and 2009, 10 times faster than inflation," according to the President Obama–directed probe and subsequent report entitled "Insurance companies prosper, families suffer: Our broken healthcare system"—Reported by talkingpointsmemo.com, February 18, 2010.
- "Blue Cross RI CEO will earn $600 000 per year" starting out—Reported by WPRI, April 26 2011.
- "Blue Shield has come under criticism for Bodaken's $4.6-million salary . . . in response to a new state law that requires insurers seeking higher premiums to reveal how much they pay their top executives. Blue Shield also pledged to return money to customers in future years when its net income exceeds 2% of its revenue, which amounts to $180 million this year"—Reported by the Los Angeles Times, June 8, 2011.
- Small-town cardiologist battles Anthem for a stress echo for a postmenopausal patient with palpitations, dyslipidemia, and mild obesity" From Cardiology Associates of Southern Kentucky, July 2011.
"They've turned me down for a precert, Dr Walton-Shirley," Tina, my secretary, said again last week. Though moderately annoyed, I navigated the automated phone menu for the Anthem reviewer line, surprised at how quickly I contacted a real human.
"This is Dr X. Patient name and number please," said the pleasant voice on the other end.
Tina pointed out the appropriate identifying numbers that I regurgitated obediently to the physician reviewer while five patients sat in their exam rooms wondering if I'd been kidnapped.
"What can I do for you today?" he asked.
"I don't mean to be rude," I started, "but what exactly is so unusual about ordering an echo and a stress cine exam on a mildly obese 59-year-old female who is postmenopausal with palpitations and dyslipidemia?"
"Well, I know it's difficult to understand," he said, "but we have these guidelines." Then he announced a website address for a reference that I didn't write down because common sense made more sense than that explanation. "I can give you the echo, but this situation really calls for just a stress ECG, at least by our guidelines," he said somewhat apologetically.
"Again, I don't mean to be difficult, but I really want to have a real discussion here with you about this," I replied. "This patient has never had a stress exam, and you want me to do a plain stress ECG? Do you know how much information can be missed with that? Do you know how many patients I've seen with a normal stress ECG and even a normal cath that have exercise-induced left ventricular outflow-tract velocity elevation? Exercise-induced pulmonary hypertension? Do you know how often I see wall-motion abnormalities on a stress cine with a normal stress ECG? Would you be satisfied with a plain stress ECG for yourself or your significant other with these risk factors?" I pressed.
"Well, again . . . it's those guidelines' writers that direct our recommendations and approvals. We use the advice and wisdom of those individuals to make those decisions."
Perhaps jumping back into the conversation a little too quickly, I blurted, "Our guidelines writers, though wonderful individuals with years of data analyses, are about 10 years behind because they can't convene often enough to keep up. If you don't believe me, look at the guidelines for primary PCI without surgical backup. We are probably 20 years behind European practices by now in the US."
To which he said politely, "I understand your frustration."
"And what exactly is the outlier here? Why can't you give me a stress cine in a 59-year-old post-menopausal female?" I asked.
"Well, she's 59, not yet 60," he answered a little sheepishly.
"You've got to be kidding me," I replied, exasperated, noting she'd be 60 in a few months. "Do you think the guidelines writers should care if she's been menopausal since age 38 or just became menopausal at 55? What if she had a complete hysterectomy when she was 25? Are you really telling me there is an arbitrary cutoff at 59?"
To which he said, "I understand it's frustrating." Then he added, with complete seriousness, "You know, there isn't enough money to go around and that's why there has to be some regulation here."
"Not enough money to go around what?" I asked myself. "The world 100 times? To pay a $4.6-million salary to every insurance company CEO in the world? To fill up the entire ocean? Oh, really? How much corporate money is enough corporate money? Is one billion dollars enough? How about two or three billion? Or perhaps 10 billion? When will it ever be enough?"
"Are you telling me they just picked the number 59 out of the air with no consideration whatsoever of the duration of her menopausal status?" I asked, again eyes rolling, pen tapping, and with patients waiting.
"Okay, I'll go ahead and authorize this one," he said, seeming to understand I would not give up on this patient's right to a thorough cardiac exam, and although I tried to remain courteous with a "don't-kill-the-messenger" demeanor, he probably sensed I was fairly steamed at this blatant case of insurance company–directed gender discrimination and hollow pretense of a focus on savings. Puh-leez.
"Here are your numbers, good for 30 days," he said in resignation.
"Thanks very much," I said, tempted to say in my best Rocky Balboa imitation, "Cut me, Mick . . . I can't see nothin'," while stumbling back to the exam room yelling "Adrienne!" Instead I just rolled my eyes again and hung up the phone, the song "Gonna fly now" ringing in my ears as I imagined myself bounding up the 72 steps at the Philadelphia Museum of Art. If only I'd had a side of beef to punch.
The unsuspecting patient on the other side of the door had no idea of the magnitude of the victory I'd just won for her or the amount of adrenalin and time I had expended on her behalf (the entire conversation condensed here for brevity). She may have thought something was up though as my face was probably 50 shades of red brighter, with a small film of sweat shimmering on my upper lip when I walked in to give her the news. She smiled when I handed her the order for a complete stress echo.
- "In the short run, it may seem like a consumer winner to rail against health insurers' profits, but placing arbitrary limits on industry profitability kills innovation and the entrepreneurial spirit--and ultimately hurts the country economically"—Mary Lou Byrd, "The case for health insurers profits."
- "It's not shoes we are buying; it's healthcare, the key to longevity, short-term wellness, workers' health, individual happiness, and productivity. People are harmed when they cannot access it, and they can't just go door to door like they would to shop for the best deal on stilettos. It's nearly impossible to find a plan in America that is caring, compassionate, and moral in its approach. The focus of legislators should be more on our concern for not killing patients than on our fear of killing the entrepreneurial spirit; after all, that spirit is alive and well in America. The big insurance corporations are thriving. It's our patients who are dying"—M Walton-Shirley MD FACC, an everyday cardiologist who spent yet another 15 minutes fighting for a stress exam on a postmenopausal patient with palpitations and dyslipidemia. ?
I'll probably have to do it again tomorrow, and no, I'm not kidding.