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It takes a village to care for a patient. That village encompasses many partners, including, in the United States at least, the patient’s health insurer. Increasingly, however, I’m aware of the many ways that such companies obstruct my capacity as a physician to provide the best and most timely care possible. After all, to the insurance company our care is considered a minus sign in the accounts log, a financial cost stacked up against the drive to increase profits.

I’m routinely confronted by obstacles put in place by insurance companies that harm the health of patients. These range from denials of care, where insurance companies refuse to cover the cost of a treatment; the need for waiting periods between patients beginning an insurance policy and being eligible for a claim; and prior authorizations, which force healthcare providers to obtain approval from insurance companies before carrying out a procedure or prescribing a certain drug. To overcome these barriers and to advocate for the needs of our patients, doctors must submit to multiple (and lengthy) telephone calls with faceless insurance representatives, peer to peer discussions, and write (and fax) multiple requests for an appeal.

I'm not alone in finding these processes onerous and worrying about their impact on patients. In a 2021 survey of more than 1000 physicians, the American Medical Association found that 88% of doctors described the burden associated with prior authorizations as high or extremely high, and 34% reported that a prior authorization had led to a serious adverse event for a patient they were caring for. 1 This red tape delays the provision of care, risking harm to patients, particularly those who are from marginalized and more vulnerable groups. A patient who is a newly arrived refugee and who cannot speak English, for example, has little capacity to advocate for themselves or navigate our cumbersome and complex healthcare system, making clinicians' advocacy for them even more critical. Yet this work also amounts to a substantial administrative burden for a workforce already struggling with burnout 2 and moral injury.

Aware of the cumulatively wearying effect of these encounters, I decided that there was something I could do as a mark of resistance. I’ve always believed that my role as a physician extends beyond the exam room and, in an intentional effort to advocate for my patients, I will now be documenting any obstruction to a patient’s care in their permanent medical record.

Clear and accurate documentation of any part of a patient’s treatment is vital for their safety as well as any transfer of care, chart audits, and litigation. I’d argue that such documentation should also include interactions with health insurers, particularly when it involves denials of care. Patients who have access to their electronic medical record should be witness in real time to any barriers to their care. After all, they deserve to know who is dictating their care and how. Furthermore, should the delay in care caused by insurance carriers lead to a poor patient outcome, this kind of documentation is critical for the purposes of peer review and litigation.

It would also be useful to gain a more precise and comprehensive understanding of the impact of delays in care caused by insurance hurdles, but to do this we need a consistent mechanism to track the data. In US healthcare, every diagnosis and patient outcome is attached to an ICD code. It’s time that delays in care caused by insurance companies are clearly documented and given their own code so that they can be tracked and studied on a larger and more detailed scale. Once this happens, we’ll be able to create a more granular picture of how insurers’ red tape is affecting patient care and outcomes, allowing us to suggest evidence based changes to the system.

Defensive medicine, practiced by many, is a well known driver of healthcare costs and I understand the need for insurance companies to deny unnecessary care. Yet evidence based care is also being denied in the process, leading to patient harm and contributing to physician frustration and burnout. This way of working creates further disillusionment about the state of the healthcare system and clinicians’ role in it. If a physician or other allied health professional has a proven track record (good report card) of appropriate prescribing and use of costly resources, their care should no longer be subject to prior authorization, or at a minimum be fast tracked and unimpeded by senseless administrative hoops.

Insurance companies should be our collaborators and partners in the management of patients. Our broken US healthcare system, however, has a long way to go in making this partnership a reality.