MB Civic

By Stephen A. Hoffmann  |  June 29, 2006  |  The Boston Globe

MANY ARE AWARE of the obstacles patients and physicians have to contend with in pursuit of quality healthcare. A watershed moment came for me last year when I diagnosed liver cancer in a 23-year-old man. No one wearing a clinical hat would disagree that this young man’s future hinged on what a PET scan would show — whether the cancer was confined to the liver or had spread — but you wouldn’t know that from the battle I waged with his insurer. It took more than three hours, culminating in an impassioned plea to a senior insurance company executive, to obtain the precious approval number for the scan. A major casualty was a canceled morning of patients.

Over the past few years insurers have heightened pressure on physicians to do what is in their best interest, as opposed to the patient’s. They dock our pay for ordering more tests or using more expensive medications than they deem desirable.

They throw obstacles in our paths — really in the way of our patients — banking that we won’t go forward, because surmounting them takes so much of our already limited time.

Roadblocks placed in the way of certain medications are “prior authorizations.” Charts must be pulled, time taken by physicians to complete them, phone calls to patients and pharmacies made, faxing entailed. As physicians, we have to find a way to fit the round pegs of our patients’ needs into the qualifying square holes that insurance companies allow. Equally, if not more burdensome, is “pre-certification,” the process required to gain approval for anything other than a simple X-ray for many patients.

All of this raises two questions: How can physicians meet patients’ unique needs given the increasing restrictions imposed by health insurance companies? How can we exercise the medical judgment we spend years cultivating when we’re routinely put on the defensive by having to “make the case” for any exceptions to the default course of doctoring insurers prescribe?

Physicians must draw attention to a system that too frequently disregards what individual patients often need. Insurance companies, understandably pressed to control escalating costs, are deterring doctors from providing individualized care under the guise that such restrictions constitute guidelines for quality. We’re graded for how well we follow these limits, as if scoring high is a mark of clinical excellence rather than a measure of our contribution to a company’s bottom line. Patient care suffers in the process.

Everyone agrees serious financial challenges exist in delivering good healthcare. Insurance company restrictions are only symptomatic of widespread problems in the system. The cost of prescription drugs is staggering. Physicians at times over-test and over-prescribe, partly in reaction to the fear of being sued. Hospital care is expensive, and employers are pushing back to reduce the high costs of health insurance. Patients could do more to take better care of themselves to drive down costs. All of us are part of the problem, and all of us must be part of the solution.

However, the restrictions physicians struggle with every day are unhealthy for our patients. Doctors shouldn’t be expected to fix high healthcare costs through rationing care, either by limiting medication, testing, or intervention. The answer isn’t to restrain us. Our job is to do what’s best for our patients.

The ownership of healthcare belongs to patients, and decision-making belongs to patients and their physicians. If good care is too expensive, that’s a problem for all of us to solve.

Dr. Stephen A. Hoffmann is a primary care physician in private practice in Framingham.