A Slave with Two Masters

A slave cannot have two masters. This is a truism.

As a surgeon, my master was my oath to always put the medical needs of my patients first. Not the hospital’s needs, not the clinic’s needs, and certainly not the insurance companies’ needs.

By law, in order to be licensed, a physician of any type must remain up to date with educational expectations and practice to “the standard of care.” The standard of care is what most physicians in any given field would do for any patient with a particular diagnosis, taking into account that each patient is different than the next. Physicians are obligated by law to hold to this standard, not just by moral conscience.

So, what are we supposed to do when an insurance company, like United Healthcare, does not have the same moral center or sense of obligation to its clients? What are we supposed to do when United Healthcare consistently refuses to approve necessary surgeries, medications, and tests?

I retired almost three years ago. When I left, automatic denials of physician submissions for approval for medically necessary surgical care was the norm for United Healthcare. It was always safe to assume that whatever the patient needed, United would turn it down. In the cases they didn’t, they might retroactively turn it down and demand return of payments made. Yes, that is correct. “Upon review of the case, our reviewers have determined that the patient did not meet criteria for surgery for their condition and therefore you have ten days to return payment for the procedure done.”

So, not only does United block access to medically necessary surgical care, but they also will take money back for the work already done by the surgeon for medically necessary surgical care. Both of these situations are so common that it has become a joke. Except that it’s not funny. United Healthcare profits in the billions by refusing to do the one job it has been assigned, and that is to honor their contract to their patients who need physician approved care.

What does this do to the physicians? I will tell you. Every day, all day long, we are faced with one difficult medical/surgical patient after another, all of whom expect us to put their lives first. We are, after all, the experts. We teach, we advise, and we move quickly when it’s necessary to prevent death or disability. So, imagine trying to do this, knowing that you are the expert, Board Certified in your specialty, only to have your patient’s medically necessary surgery cancelled by the insurance company. All day long, this goes on. It sucks the life out of the clinic nurses and the surgeons trying to take care of the patient. We have a patient on the table ready to go to sleep for a major case, and then we get a phone call from our nurse saying that we need to do a peer-to-peer review of another case because payment has been denied. We need to be focused on the case at hand, but now we are distracted by the insurance company.

And let’s talk about “peer-to-peer” review. It is supposed to be a conversation with another physician who is also Board Certified in your area about the patient’s care. But this is not what happens. Instead, you get a general internist or a primary care physician on the line, not a surgeon. And they argue with you, even though they are not an expert. And they have the final say rather than the surgeon who has been taking care of the patient. The peer-to-peer insurance company consultant has not examined or seen your patient, nor have they talked to them. They have not reviewed the radiologic studies with their own eyes. Frequently, they have not even bothered to review all the details in the reams of pages of information my office staff sent them to support the decision for surgery. Not once, in my thirty-year career, was an insurance company decision not to pay for a covered patient’s surgery correct. Not once! And yet, as the years went by, I was hassled more and more and more by this system. The emotional toll taken and the stress caused by this never-ending onslaught from United Healthcare was disastrous for my sense of well-being. Every denied case turned into a fight between me and United Healthcare. Every day I had to put on my emotional armor to go to war, it seemed.

A physician cannot be both a slave to their patient and a slave to the insurance company. We have already chosen our master, the person we are committed to supporting no matter what. We cannot be slaves to the business of profiteering that United Healthcare has so fully embraced.

What about other health insurers? Anthem could be a problem at times. Iowa Blue Cross/Blue Shield had a very good system and rarely interfered with the care I needed to deliver. Principal went through a phase in the 2000’s where they were instigating internal investigations of any surgeon who performed “too many” specific treatments for certain conditions. I was targeted by one of these investigations because I was by far the busiest surgeon in Iowa in the treatment of gastroesophageal reflux disease. I was the busiest because I was the most expert, but that didn’t stop them from trying to find a way to blackball my practice. I found out they were doing this investigation by accident while trying to get to the bottom of a decision they had made not to cover a case. So, I had to get an attorney involved to get them off my back.

This sort of thing wears the surgeon down. It wears the case managers down. It wears the nursing staff down. And it is extraordinarily damaging to the patients emotionally and psychologically.

Twice I had cases that I could not get approved. Only twice. But that’s because I would never accept “no” for an answer. I was highly expert in my field, and I just wouldn’t put up with it. I was incredibly aggressive about holding the insurance company to task. If they assigned a non-surgeon as my peer-to-peer, I would demand they find a surgeon to talk to me, someone who understood my specialty. If they had not done their homework and reviewed all the information sent in to support the case, I would rip them apart for not doing their job. I would also question their ethics and morals and ask them who had advised them to routinely refuse approvals. I would torture them as much as they were torturing me. I told my patients to write letters to them and get attorneys to write letters. They were wasting my valuable time, so I wasted theirs in return.

Yesterday I saw a video of a young surgeon who decided to quit surgery entirely because of the ongoing “moral injury” she was enduring from knowing her patient’s needed surgery and not being able to get their surgeries approved for payment from United Healthcare. It put her in a constant state of anxiety and distress to know that she could not, because of the insurance company, do her job and uphold her commitment to “do no harm” in her job. This is entirely unacceptable.

The entire practice of prior approval should be completely discarded. It is nothing more than a mechanism to deny and delay care and maximize profits for capitalistic health insurance companies so their investors can be paid handsomely and their CEO and business managers can financially rape the system for personal financial gain.

We are way past the point when health care should have been overhauled in the U.S. No one should have to be worried about being bankrupted by the insurance companies or denied care. No one should have health insurance that is tied to employment. No doctor should have to put up with abuse and manipulation from the insurance companies. Health care should be available to all whenever it is needed, period. It should be broadly government supported. And all private health insurers should be not-for-profit. Medicare should have been made the national health care insurance program for everyone when it very first began, starting with birth.

The patients are furious and so are the clinicians who are actually doing the work of healing the sick while being constantly harassed. Clinicians need to rise up as one and demand immediate change and fight for every patient like a tiger, and congress needs to take this problem seriously, stop the politicizing, and fix it, once and for all, making it impossible for private insurers to be running the show. When a patient is sick, you never hear them say, “Is there an insurance company CEO nearby who can help me,” do you. Nor do they ask for a business manager. Nor do they ask for an insurance clerk. They ask for a DOCTOR, and rightfully so.

Health insurance companies, get out of the way. Everyone is sick of you throwing up roadblocks to the delivery of patient care. Where is your ethical center? Where is your moral center?

And congress – how nice that you’ve arranged for nothing but the very best healthcare for yourselves while hanging the American people out to dry. You’re just as bad as United Heathcare and you’re not doing your job as public servants on behalf of the American people. Step up for once in your lives and do the right thing and solve this problem once and for all.