For the sake of this article let’s call him Dr. D, a primary care doctor in a small town. He arrives at his clinic early every day, usually leaves around 7 p.m., and has another hour or more of paperwork to do after he arrives home. He doesn’t mind the long hours – he grew up on a small farm and understands hard work. After 30 years of practice he has earned the respect of the community; his patients know that his concern for them is genuine. He can be blunt when necessary, lecturing them like a father, or he can comfort them when a gentle word is needed. All of his patients know his never-faltering sense of humor and his ear-to-ear grin. His smile disappears when I ask him about The Affordable Care Act and how it has affected his practice.
Every day he hears the complaints about the ACA (Obamacare) and health insurance in general – how insurance rates have skyrocketed, the high deductibles and out-of-pocket expenses, the unneeded services covered (a single young man asking why he needs OB/GYN coverage) and needed services denied.
“The ACA was supposed to open up health care. It hasn’t happened. In fact, just the opposite. The ACA plan in our state, AMBetter, is insurance in name only. It is just another major medical plan, no different. I spend my day telling patients ‘I’m sorry but your insurance won’t cover what you need.’”
Most medical specialists won’t even take AMBetter. It is too difficult to get approval for needed services and the reimbursements are poor. Dr. D accepts it because, in his own words, “I’ve never once done a wallet biopsy on a patient.”
But the ACA has made his life much harder. “I no longer think ‘How am I going to treat this patient’ but ‘How can I code the insurance to get it done.’ “
He has one nurse whose primary job is to deal with the insurance companies. She spends most of her day on the phone trying to get approval for needed treatments. It is a difficult and frustrating task.
One particular patient’s ordeal stands out. A young man was, literally, hit by a tornado. The tornado scooped him up, stripped the clothes from his body, twisted and bent him until he tumbled to earth in a field two and a half miles away. He was naked, bloody, and battered but still alive. Unable to stand, he dragged himself to a nearby road where he was found and taken to the hospital.
Dr. D saw him over a period of time but the patient never recovered the ability to walk, specifically, to put any weight on his left leg and hip. X-rays revealed no cause so Dr. D filed a request for an MRI. The request was denied. Dr. D’s employee called and spoke with an employee at the insurance company. Again, request denied. Dr. Don personally called and talked with them. Sorry, he was told, the X-rays were negative so they could not authorize an MRI.
One morning Dr. D walked into his office and announced that he wasn’t leaving until he talked with an actual physician at the insurance company. His nurse immediately placed the call. At 2:30 in the afternoon she was informed that a doctor would be on the line shortly.
An hour and fifteen minutes later the physician picked up and, after a short but serious talk, Dr. D finally got approval for an MRI for his patient.
The MRI showed a vertical fracture of the femur. Surgery was required, an intra-medullary rod was inserted the length of the bone, and today the patient is well and walking again. Time from date of injury to date of resolution? 15 months. Think about that. 15 months of confinement to a bed or wheelchair. 15 months of pain.
“They talked about Death Boards when the ACA was being debated,” Dr. D says with a shake of his head. “There is no board, just a clerk with a notebook of guidelines and protocol.” It is suffering and death by bureaucracy.
“Does this system make any sense?” Dr. D asks then quickly answers his own question. “Government has failed the Common Sense Test.”
Meanwhile a new nickname has sprung up in this area for AMBetter. It is not elegant but it is accurate – AIN’TBetter.