December 12, 2017
Some would say the American healthcare system is rigged or broken. One of them is Dr. Linda Girgis, a board-certified family physician in South River, New Jersey. In a recent blog of hers — titled Navigating the Complexities of the Healthcare System – she maintains it’s not enough to know what a patient needs. Doctors need to know how the system works and then help patients understand how to “work” the system.
The crux of the problem, she says, lies in healthcare maze created by the hodgepodge of plans patients choose, each with its own set of terms and rules governing deductibles, copays, and coverages.
Dr. Girgis cites two examples of how this can sometimes work against the best interests of patients and doctors:
A doctor wants a patient complaining of back pain and numbness in one leg to have an MRI to check for a herniated disk or spinal cord compression. But the patient’s insurance company requires that he or she must first undergo a less expensive (and less useful) x-ray exam and then endure weeks of ineffective physical therapy for an undiagnosed condition before finally authorizing the MRI, effectively prolonging the patient’s suffering.
Another example has to do with changes in an insurer’s drug formulary, which can force a patient with asthma to switch inhalers from one that worked well to another that costs less on the insurer to test if it works for the patient.
While providers can sometimes find workarounds and help with appeals, she says today’s patients need to become better informed about their coverage. They should:
Educate themselves. Ask questions. Doctors have lots of experience dealing with coverage issues and can help.
Fight back. Don’t give up when a needed authorization is denied. Make calls, file appeals. Insurance companies expect you will just give up.
Find a patient advocate. Your doctor, family member or trained patient advocate can, as Dr. Girgis puts it, “lead the charge for getting the care our patients need.
Navigating the Health system inspired ICmed to create our platform to equip doctors and employers with an engaging tool to inform their population of new developments in coverage as well as share health literacy straight to their phones. A more empowered and knowledgeable patient, we believe, will lower hospital readmissions, improve overall health and reduce costs.