Part II

When I was a new attending physician on the faculty two or three years out of fellowship, I was doing my one-month rotation as the inpatient oncologist. One of the patients on the ward was an unfortunate lady in her mid-60s with terminal breast cancer who was semi-comatose and clearly had only a few days to a couple of weeks to live. One day she was absent when we made rounds, and the next morning she reappeared with bandages on both eyes. Believe it or not, an ophthalmologist had taken her to the operating room in order to remove cataracts from both of her eyes. She died about 10 days later, but perhaps she could see the angels more clearly when she arrived at Heaven’s gate.

We pursue medical care within a free enterprise, fee-for-service system and I do not in any way advocate for a single payer system as in the nationalized healthcare systems in the European Union. I believe strongly that our system leads to superior care on the whole. However, it also leaves itself open to abuses of many sorts, as the anecdote above illustrates. While this was obviously a particularly egregious episode, it was only a bit more extreme than many such abuses that transpire in the system.

The problems arise from both the healthcare providers and the patients. Insured patients are mostly shielded from payments and so do not inquire about the costs of what is done to or for them. An insured patient undoubtedly expresses more concern about the cost of yogurt or eggs than about how much the pembrolizumab (Keytruda) I am prescribing will cost; indeed, I cannot recall a patient ever inquiring how much it would cost; parenthetically, it is approximately $25,000 per treatment and given every three weeks. Insured patients, of course, do not pay this and even if there is a co-pay, the drug companies have been savvy enough to establish support systems to provide co-pay support to patients to dramatically lessen the blow. And the healthcare provider or his/her institution gets a markup for providing the drug. My comments here do not apply to the uninsured.

As described in the opening paragraph, there are multiple ways in which healthcare providers can increase their revenues without seeming to do so—indeed, while seeming to apparently be benefiting the patient. When insurance executive Brian Thompson was recently murdered in New York City, and there was sympathy for Luigi Mangione, the alleged assassin, on the grounds that the insurance company had acted in negative ways, my reading indicated that the main complaint was that insurance companies frequently turn down or do not authorize procedures that were requested by practitioners. Obviously, the alternative would be that there would be no limitations on what doctors could order or do. The cataract removals in the first paragraph would now not be authorized by an insurance company (I think).

In oncology it is routine to obtain scans for surveillance after surgery for solid tumor patients on a regular basis. One can either order CT scans or PET scans—they are about equal in efficacy for this purpose. Nonetheless, the cost of these tests varies—a PET scan will run about $6,000-$7,000 minimum up to $10-$11,000, while CT scans of the chest/abdomen/pelvis will tally about $1,000. Therefore, I only infrequently order PET scans for surveillance. When I do, I often get denied authorization for PET scans, but a call to the insurance company by me or my nurse practitioner with an explanation of the reason for why a PET scan was ordered will almost always lead to approval of the PET.

I am not an expert in this complex area, but it seems to me that these problems were exacerbated by the passage of Obamacare in 2010 which expanded insurance coverage but basically by providing insurance of inferior quality. Younger people were required to purchase health insurance, but it was at an outrageously high premium that was inconsistent with their health issues because they were subsidizing the elderly. The other part of the Obama solution was a vast expansion of Medicaid to 100 million Americans. This is theoretically great insurance in that it has outstanding coverage in theory, but because of the huge number of people on Medicaid, states are compelled to try to hold down costs by limiting the reimbursement rates for providers. A study in 2019 showed that pre-Obamacare Medicaid patients had 50% the access to physicians that privately insured patients did; post-Obamacare, this went down to one-third as likely because of further reductions in reimbursement rates. A further problem is that, despite reduced access, Medicaid patients have no restraints on their use of services and so Medicaid beneficiaries overuse the system; visits to the emergency room substitute for much cheaper trips to a primary care physician for routine problems.

Thus, one major insurance-related complaint is difficult access to certain physicians. This is primarily for the Medicaid-insured patients, though now this problem is expanding to many privately insured patients as well; certain physicians refuse all insurance, simply bill the patient, and make it your responsibility to obtain reimbursement.

As for pre-authorization, this seems to be a necessary step to regulate the behavior of providers and to make certain that guidelines are followed as well as to keep greed in check. If guidelines provide for screening colonoscopy to begin at age 45, what stops the performance of a screening colonoscopy at age 40? If there is a legitimate reason to do one, the provider has the opportunity to explain it to the insurance company physician.

Once again, I would invite readers to email me their thoughts on the issues raised in these articles as they appear in the Link and, depending on the response, I will put together one or two articles with readers’ comments after my eight articles appear.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: ain1@columbia.edu.

 This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.