• May 30, 2024

Who Is Responsible for Your Health? Your Doctor or Your Insurance Company? 2023

Patients still think physicians decide health care. They believe their doctor should prescribe medicine following a consultation and exam.

As their doctor, I hope so. Sadly, that seldom happens.

A radiologist phoned me last week to tell that a patient’s CT scan revealed intestinal irritation. The insurer would only authorize MRIs ordered by gastroenterologists, so I had to urge the hospital’s radiology department to battle for the radiologist’s recommendation.

The patient suffered stomach pain, and the second test verified the infection, sparing his life, but the insurance company didn’t care. It didn’t choose a doctor either. My office manager worked hard to get the patient into a gastroenterologist the same day for the best therapy.

Treatments are typically the same. Too frequently, your health insurance provider—not your doctor—determines which antibiotic, blood pressure, or cancer treatment you can take. My options are restricted, and pharmacies seldom stock non-insurance-covered medications and often turn people away without alerting doctors.

Health insurers authorize tests and treatments too often.

Today, everything is digital. Wegovy and Ozempic, fancy weight-loss medications, have garnered attention for not being available or paid by insurance for off-label usage, but the problem affects many more pharmaceuticals, including the newest insulins. Despite not limiting choices, the buck ends at my office door.

Not only private insurers. In most states, Medicaid and Medicare (Part D or Medicare Advantage with an HMO) have rigorous formularies.

AI will help me decide what’s best for a patient by giving me additional medical data and observations. It may also make insurance judgments difficult to challenge.

In essence, I will have to negotiate with a computer to gain exceptions for your expensive tests or treatments, and you may have difficulties understanding that a machine or algorithm rejected you rather than a doctor.

What do?

I don’t think “leveling the playing field” implies promoting insurance companies’ disease-oriented high-risk pool of patients’ one-size-fits-all solutions.

It doesn’t mean negotiating cheaper prescription costs while rewarding the semi-invisible middlemen, pharmacy benefit managers (PBMs), with rebates and profits. It doesn’t imply raising copays and deductibles for poor and elderly people and limiting their choices when technology promotes individualized solutions.

“Leveling the playing field” means paying generic medicine producers, who control 90% of the U.S. prescription medication industry, to develop more product rather than fleeing a competitive market with a slim profit margin. Copays should boost customer options, not restrict them. Copays should allow access to more expensive drugs.

The doctor-patient relationship and its benefits must be deregulated.

As a doctor in clinical practice, I must be in charge—not only in my patients’ eyes—to live. My patients need incentives for colonoscopies, mammograms, weight reduction, exercise, and the latest blood pressure and cholesterol-lowering medications.

A doctor should diagnose and determine in the patient’s best interest, not a health insurer or AI software.

Dr. Marc Siegel, clinical professor of medicine at NYU Langone Medical Center, has written many books, including “COVID: The Politics of Fear and the Power of Science.” SiriusXM’s “Doctor Radio” presenter and medical director is him.

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