Thank you for sharing this. As a patient with multiple chronic conditions I spend a huge amount of time ensuring that I know 1) what drugs are on formulary, 2) what is step therapy, 3)what needs prior authorization and, 4) when those authorizations should run out. Of course the formulary changes at least every 6 months and despite approving a medication for a year in a prior authorization, insurance companies often refuse to fill prescription and require new PAs.
I also love spending a year or two working through step therapy only to “get to the drug” only to find it’s no longer on formulary.
I recognize how much time and effort all this takes from the doctors office and I hate that the system has evolved into this. I’m a nurse who graduated in the late 1980s and became an advanced practice nurse the early 1990s. I’ve seen many improvements in healthcare, but I definitely don’t feel like the impact of insurance on practice has been overall positive.
Wow, you are a wealth of knowledge with all of your experiences both as clinician and patient. I am shocked to hear that going through step therapy only to find the target medicine is no longer on formulary must be another "strategy" insurance companies employ to cut cost.
Mostly I work with patients who are of lower socioeconomic status and are less empowered to advocate for themselves. I aim to fight every insurance denial. But I have so many. Sometimes one or two get missed in the system and I won't notice until months later, when patients come in not better. But they don't complain! It breaks my heart.
How do we, as patients who pay our premiums, take back control over the insurance industry? If we all worked together and stood up against this nonsense of the insurance industry dictating our health care, we could change things. Or am I crazy?
The perversity of all of this is that the nominal purpose of insurance is to distribute risk across a population, and nothing more.
The insurance model meets the needs of industry in which employees are more-or-less interchangeable parts. The companies need these parts to be in good working condition throughout their operating life, so insuring them, like they would any capital asset, on a time-limited basis (say, annually) makes economic sense for them. This financing mechanism fits their need to replace worn-out parts. Once they swap out an employee, they have no further obligation to maintain the health of an obsolete part.
The problem of the insurance model for the individual patient is that body ownership isn't like car ownership. You can periodically swap out an aging car for a new model, but nobody can swap out their body. Instead, the only path is maintenance inevitably ending in death.
That means another model, one in which everyone buys into a healthcare system over a lifetime, building up equity in the system which isn't reset annually, is inherently better for stability. In so-called socialized or national healthcare systems, taxes are investments in the system, rather than premiums for defined risk periods.
The national healthcare systems have their own sets of problems, but from the population metrics, end in better health outcomes from childhood to early old age. On the other hand, these systems spend drastically less at the beginning and ends of life. Neonatal care for severely premature babies is extraordinarily expense, as is aggressive intervention for old people. US laws legally obligate care that are routinely unavailable in the national healthcare systems.
How do you shoulder this heavy burden?I guess like we all do,one day at a time while hoping for better times.I just found you here accidentally and it’s a good thing.I needed to know all your stories.thank you and your mom.
As an ICU Nurse and also a mother of 3, I felt this in my soul. We work within the confines of a very challenging system, I wish more people understood how much we all care very deeply about our patients.
Thank you Kristin! I always say ICU nurses are honorary doctors -- you save more lives than the rest of us haha. And yes, I know you feel this anger, desperation, disappointment inside. And at times, people think of us as the enemy because we are the "face' of healthcare, their frustration has to go somewhere. That's another tough aspect.
Haha very true and thank you. In the best systems, we also all know our roles very well. Critical Care is not at all like other areas of the hospital. When I go to the pediatrician I always tell them not to talk to me like a nurse. Peds is not my specialty!! So o have so much love, respect and gratitude for you and what you do.
The American medical "system" has turned into an extractive industry over the last 40 years as predicted in Paul Starr's "The Social Transformation of American Medicine." He argued that medicine, which was mostly a collection of small autonomous medical practice, would inevitably be corporatized just like other types of small businesses. He thought that "roll-up" was inevitable, although the path of health maintenance organizations was more likely to preserve some of the professional autonomy of physicians. He warned, however, that the more likely path was an industry devoted to maximizing shareholder value, in the mistaken belief that healthcare could work as a free market, like any other.
40 years of pretending that medicine is like any other human activity has proven him right, with its perverse incentives leaving almost everyone terrified of being economically crippled by medicine.
It's also helped turn people against one another, angry that other people may be getting healthcare at their expense.
I couldn't have said it better myself. Both patients and physicians are caught in the middle, pitted against each other, and prevented from doing what we really wanted/needed to do.
I married quite late in life and my husband is so so healthy and originally from the UK, so my existence has been eye opening for him. He often questions how most patients get the care they need because I am constantly having to intervene, follow up, and push to ensure I get care.
My current insurance requires that I have ICD and/or CPT codes for them to even tell me if the company covers the treatment and usually they don’t do prior authorization just say “we cover the treatment in cases where it’s medically necessary”, but won’t provide criteria for medical necessity. It forces one to choose whether you will risk testing and treatment hoping it will be judged medically necessary. It’s a gamble - many things are covered quite well by the plan (sometimes up to 100%), but I’ve had denial after denial that I’ve had to appeal. Even though I tend to end up getting them to pay, the time, phone calls and paperwork feels like a circle of Dante’s Hell.
I volunteer time as I can helping people with some of my complex medical issues navigate medical systems and insurance companies. There isn’t any easy solution to the mess of healthcare reimbursement, but what we have now definitely is getting worse for the patients and providers
I felt this 🤍 Thank you for all you do!
Girl you do this day in and day out!! Fightin the good (but terrible) fight!!
Thank you for sharing this. As a patient with multiple chronic conditions I spend a huge amount of time ensuring that I know 1) what drugs are on formulary, 2) what is step therapy, 3)what needs prior authorization and, 4) when those authorizations should run out. Of course the formulary changes at least every 6 months and despite approving a medication for a year in a prior authorization, insurance companies often refuse to fill prescription and require new PAs.
I also love spending a year or two working through step therapy only to “get to the drug” only to find it’s no longer on formulary.
I recognize how much time and effort all this takes from the doctors office and I hate that the system has evolved into this. I’m a nurse who graduated in the late 1980s and became an advanced practice nurse the early 1990s. I’ve seen many improvements in healthcare, but I definitely don’t feel like the impact of insurance on practice has been overall positive.
Wow, you are a wealth of knowledge with all of your experiences both as clinician and patient. I am shocked to hear that going through step therapy only to find the target medicine is no longer on formulary must be another "strategy" insurance companies employ to cut cost.
Mostly I work with patients who are of lower socioeconomic status and are less empowered to advocate for themselves. I aim to fight every insurance denial. But I have so many. Sometimes one or two get missed in the system and I won't notice until months later, when patients come in not better. But they don't complain! It breaks my heart.
How do we, as patients who pay our premiums, take back control over the insurance industry? If we all worked together and stood up against this nonsense of the insurance industry dictating our health care, we could change things. Or am I crazy?
It feels like you are not crazy and I’m not crazy, but the world is crazy…
The perversity of all of this is that the nominal purpose of insurance is to distribute risk across a population, and nothing more.
The insurance model meets the needs of industry in which employees are more-or-less interchangeable parts. The companies need these parts to be in good working condition throughout their operating life, so insuring them, like they would any capital asset, on a time-limited basis (say, annually) makes economic sense for them. This financing mechanism fits their need to replace worn-out parts. Once they swap out an employee, they have no further obligation to maintain the health of an obsolete part.
The problem of the insurance model for the individual patient is that body ownership isn't like car ownership. You can periodically swap out an aging car for a new model, but nobody can swap out their body. Instead, the only path is maintenance inevitably ending in death.
That means another model, one in which everyone buys into a healthcare system over a lifetime, building up equity in the system which isn't reset annually, is inherently better for stability. In so-called socialized or national healthcare systems, taxes are investments in the system, rather than premiums for defined risk periods.
The national healthcare systems have their own sets of problems, but from the population metrics, end in better health outcomes from childhood to early old age. On the other hand, these systems spend drastically less at the beginning and ends of life. Neonatal care for severely premature babies is extraordinarily expense, as is aggressive intervention for old people. US laws legally obligate care that are routinely unavailable in the national healthcare systems.
How do you shoulder this heavy burden?I guess like we all do,one day at a time while hoping for better times.I just found you here accidentally and it’s a good thing.I needed to know all your stories.thank you and your mom.
Thank you so much Kathy for reading my stories! And yes, I am certain we all do. And I count my privileges every day.
As an ICU Nurse and also a mother of 3, I felt this in my soul. We work within the confines of a very challenging system, I wish more people understood how much we all care very deeply about our patients.
Lovely article Doc.
Thank you Kristin! I always say ICU nurses are honorary doctors -- you save more lives than the rest of us haha. And yes, I know you feel this anger, desperation, disappointment inside. And at times, people think of us as the enemy because we are the "face' of healthcare, their frustration has to go somewhere. That's another tough aspect.
Haha very true and thank you. In the best systems, we also all know our roles very well. Critical Care is not at all like other areas of the hospital. When I go to the pediatrician I always tell them not to talk to me like a nurse. Peds is not my specialty!! So o have so much love, respect and gratitude for you and what you do.
That is heartbreaking. We need to fix this!
we absolutely have to!
That’s a beautiful painting. Did you paint it?
no lol! I should have credited it, I obtained the license for this artwork via Adobe!
The American medical "system" has turned into an extractive industry over the last 40 years as predicted in Paul Starr's "The Social Transformation of American Medicine." He argued that medicine, which was mostly a collection of small autonomous medical practice, would inevitably be corporatized just like other types of small businesses. He thought that "roll-up" was inevitable, although the path of health maintenance organizations was more likely to preserve some of the professional autonomy of physicians. He warned, however, that the more likely path was an industry devoted to maximizing shareholder value, in the mistaken belief that healthcare could work as a free market, like any other.
40 years of pretending that medicine is like any other human activity has proven him right, with its perverse incentives leaving almost everyone terrified of being economically crippled by medicine.
It's also helped turn people against one another, angry that other people may be getting healthcare at their expense.
I couldn't have said it better myself. Both patients and physicians are caught in the middle, pitted against each other, and prevented from doing what we really wanted/needed to do.
I married quite late in life and my husband is so so healthy and originally from the UK, so my existence has been eye opening for him. He often questions how most patients get the care they need because I am constantly having to intervene, follow up, and push to ensure I get care.
My current insurance requires that I have ICD and/or CPT codes for them to even tell me if the company covers the treatment and usually they don’t do prior authorization just say “we cover the treatment in cases where it’s medically necessary”, but won’t provide criteria for medical necessity. It forces one to choose whether you will risk testing and treatment hoping it will be judged medically necessary. It’s a gamble - many things are covered quite well by the plan (sometimes up to 100%), but I’ve had denial after denial that I’ve had to appeal. Even though I tend to end up getting them to pay, the time, phone calls and paperwork feels like a circle of Dante’s Hell.
I volunteer time as I can helping people with some of my complex medical issues navigate medical systems and insurance companies. There isn’t any easy solution to the mess of healthcare reimbursement, but what we have now definitely is getting worse for the patients and providers