Medical care: More than just the doctor and patient

How does medical care get delivered? If portrayals of doctor visits in the movies and on television tell us anything, it’s as simple as this: A patient visits the doctor, the doctor prescribes a treatment, and the patient obtains the doctor’s recommended treatment.

But as many people ultimately learn firsthand, the provision of care is much more complicated than the doctor-patient dyad we have come to expect.

Our first-year medical students learn this early in their education. As part of their introduction to medical ethics this year, they worked through a case study involving inpatient versus observed status and how that impacts a patient’s ability to afford a skilled nursing facility based on insurance coverage, adapted from a fact pattern in the New York Times and the subject of an ongoing class action lawsuit.

For some students, this is the first time they have seriously considered how insurance coverage – sometimes more so than their expert medical judgment – can be a driving force behind the medical care a patient receives. But it will not be the last. As they will learn, several other aspects of insurance can dictate accessibility of and compliance with treatment plans.

For example, the simple fact of whether or not the patient has insurance, and what type of insurance they have, will impact what care is accessible and if the patient will experience insurance-based discrimination.

Another consideration is the deductible and its influence on the decision whether and when to undergo an elective procedure. A patient’s choice to have the procedure may depend entirely upon how much of their deductible they have already paid, and where they are in the calendar year with respect to their insurance policy.

Or consider the denial of care based on coverage, either because the treatment sought was not covered under the terms of the patient’s plan or because the provider was out of network.

These all seem fairly straightforward, but do not cover the full range of reasons insurance can influence access to care. Even if the proposed treatment is covered by the plan, an insurance company may ultimately decide not to pay for an emergency room visit if the medical diagnosis is determined to be a non-emergency.

This situation has made the news several times in recent months. The practice has received significant criticism as it can create a dangerous situation in which we may force patients with no medical background to make difficult medical determinations about the seriousness of their condition while sick or in severe pain.

Is this permissible? The law generally permits insurance companies to assess the appropriateness of care, but often with some restrictions. Nearly all state insurance codes include provisions for medical utilization review. While the specifics are often insurance-plan-dependent, some states do not even require that the individual responsible for making an adverse determination be a physician in a same or similar specialty – or even a physician at all.

On one hand, review of medical claims make sense. It allows insurance companies to minimize unnecessary and inefficient care and control costs. In cases like the emergency room example described above, it can discourage emergency room utilization for non-urgent concerns out of convenience.

On the other hand, we have now inserted an uninvolved third party into the doctor-patient relationship. An individual who has no personal familiarity with the patient or the conversations surrounding treatment (beyond what is in the medical record) may have the final say.

When you need medical care, your treatment decisions are made with your doctor and, on occasion, a surrogate decision-maker. However, other factors can creep in. We’ve covered several on the blog, including physician shortages, political climate, and geographic location. Even now as we add insurance considerations to the long list of factors impacting care, we have only begun to scratch the surface of the complex system in which care is provided.

-By Leah Fowler, J.D., health policy program manager in the Center for Medical Ethics and Health Policy at Baylor College of Medicine

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