The opinions in this article are my own and I am not writing as a representative of my employer or the Minnesota Psychiatric Society.
When I started my medical training 37 years ago, my only focus was on becoming a competent physician. There was little thought given to the systems of care that support the practice of medicine.
My first job after residency was as a Navy psychiatrist where all patients had health care essential to maintaining a healthy workforce. Only after leaving the Navy did I encounter people with poor insurance or no insurance. Over time, the problems caused by greed in our profit based systems became painfully evident and a source of personal burnout.
Thankfully, the next generation of physicians is thinking about systems of care. Please see Beret Fitzgerald’s companion article.
In a free market, price is determined by what the market will bear. When a patient has a life threatening illness, the price of treatment can reach extortion levels. We can opt out of luxury items but not life-saving treatment. Yet Congress forbids Medicare to negotiate for lower prices.
Insurance companies are threatened by these high prices. In response, they engage various business practices to defend their profits. These practices have little to do with clinical care and when profits are threatened, they are no longer in it for your health.
Here is how this plays out in the clinic.
Many of my patients have complex and resistant psychiatric conditions and have already tried a number of medications or have had numerous side effects. Much effort is spent working with the patient to choose a treatment with the best chance of being safe and effective. When the treatment includes a medication a prescription is sent.
The patient goes to the pharmacy but too often leaves without their medication because a prior authorization (PA) is required by insurance. This process can take weeks and may involve “fail first” steps which can take even longer. Patients must try and “fail” two cheaper alternatives. Sometimes the alternative is clearly inferior or less safe or has the very side effects the patient wishes most to avoid.
This is appalling and exceedingly frustrating for both the patient and me. Treatment is delayed. They suffer if the alternatives do not work or are poorly tolerated. They know it was not the treatment decided upon in the office. Often additional appointments and phone calls are needed to support them through the process. While my employer helpfully provides a team to interact with the insurance company, it raises total costs. If the prior authorization is denied, I must compose an appeal letter which takes time away from caring for other patients.
One gets the distinct impression that this system is designed to be burdensome in order to wear down the clinician. Those who create these practices do not need to face the patient and cannot be reached. Efforts by the Minnesota Medical Association to pass legislation to limit PA’s have been effectively blocked by the efforts of insurance company lobbyists.
What kind of a system expects patients to fail, delays care, shifts costs to other parts of the system and asks patients to use inferior or riskier treatments? What kind of system promotes frustration and burnout in providers? What kind of system unfairly excludes part of our population?
Well, that is our current system.
There is a better way. Single payer, universal health care.
Hardwig was born, raised and educated in Minnesota. He obtained his undergraduate education at Rainy River Community College (1977-79) and University of Minnesota, Duluth (1979-81). Medical training was obtained at Mayo Medical School (1981-85) and psychiatry residency at Mayo Graduate School of Medicine (1985-89). Board Certified in psychiatry and neurology 1991.