There’s a war raging in doctor’s offices— and in each case the winner’s decision can have a significant impact on the patient’s outcome.

Increasingly insurance companies are overruling physicians’ recommended treatment plans in the name of cutting costs. This dynamic is problematic because in medicine, as trained and educated professionals, we doctors base our therapy decisions on the best available data, and apply what we know to be most effective to each individual clinical setting and patient.

Insurance companies, on the other hand, are most concerned with risk and cost estimates.

As a board-certified cardiologist, I unfortunately spend a great deal of time discussing treatment plans with insurance companies, and this takes me away from my patients.  Many of the tests, treatments and procedures that I deem necessary are often denied by insurance company reviewers. Although these reviewers are physicians whom the insurance company has hired, in most cases, these individuals do not have the same level of training or expertise that I possess. Sometimes, they have no clinical experience at all, and they simply read from a script or a checklist during our so-called peer-to-peer review call. Many reviewers do not even know the clinical guidelines that the American College of Cardiology has set forth.

Even after presenting the clinical data and sharing the national guidelines with an insurer, oftentimes, the treatment is still denied. Many insurers require you to use an alternative, less effective and, of course, cheaper therapy first.
 

Opening my eyes to patients’ health care struggles

As a physician, I typically only see one side of the insurance issue— on my end, fighting this battle means filling out paperwork, making phone calls, and coping with frustration.  However, for the patient, these issues can become much more complex— and can ultimately impact their health.

Recently, this power struggle affected me as a patient and a physician.

For the last four years, I have taken medication to control high cholesterol, but finding the right drug cocktail was a challenge at first. My physician recommended several different drugs, but they were ineffective or posed intolerable side effects. Finally, we found a combination that worked well for me: Crestor and Zetia.  I remained on these two drugs for more than 18 months and had the best cholesterol of my life.

But last September, my insurer, United HealthCare, notified me that they would no longer be covering Crestor.  They suggested I try other drugs.

I immediately appealed the decision and provided United with the record of my trials of other cholesterol drugs.  They denied my appeal and asked that I take one more try at an alternative.  Having no other real choice, I complied for nearly six months.  Ultimately I could not tolerate the alternative drug and made a second appeal to the insurance company.  They immediately denied my appeal again.

This left me with two choices that I suspect many of my patients have faced in the past: either pay out of pocket— to the tune of nearly $500 per month— for my drugs, or simply go untreated.

This process has opened my eyes to the challenges many of my patients face.  If a cardiologist like me cannot get the medications I need, then how in the world can a regular patient? How can we expect patients to engage in their own health care and comply with treatment plans if insurers fail to do their part?
 

Insurance and Obamacare: More bad news for patients

As we have seen in the past six months, the Affordable Care Act (ACA) has become a significant liability for insurers.  The rising costs and the addition of high-risk populations has resulted in multimillion dollar losses for United HealthCare, Human and, most recently, Aetna.

Insurers are for-profit entities and have an obligation to their shareholders to make sound financial decisions.  Now, three of the largest ACA participants have vowed to significantly reduce their presence going forward.  This effect may result in more limited access for patients, fewer choices, and higher costs.  The average Silver Plan is estimated to rise by 15 percent— in some states, these premium increases may approach 45 percent.

While I do not blame them for dropping out of the exchanges, something must be done to improve regulation of insurers and better protect patients.  Lawmakers must act to change the ACA and include insurance regulation as part of any new legislation.  We must continue to let doctors treat patients.

When we involve for-profit entities such as insurers in clinical decision making, we cloud the picture and create the opportunity for bias— and, ultimately, patients suffer the consequences physically.
 

Kevin R. Campbell, MD, FACC, is an assistant professor of medicine, division of cardiology at University of North Carolina. He is the author of "Losing Our Way in Healthcare."