By JL Lycette, MD
It is 4:15 PM in my clinic, and I’m running almost an hour behind.
One of my earlier patients, booked for a “routine” follow-up appointment, arrived acutely ill and thus required more of my time and attention than the schedule allotted for. Accordingly, every patient booked after that has ended up waiting for me. And, as I’m a cancer physician, each of them requires—and deserves—all my time and energy. There are no “easy” visits here.
By the end of the afternoon, I’ve given up on any possibility of getting back on track and simply inform my staff to tell every patient upon check-in to expect a long wait.
I have two more patients to go when I get a ping on my right-side monitor, a direct message from someone in our “prior authorization” department. Nowadays, doctors receive so many electronic notifications on various platforms that most of us have dual monitors, one side for the Electronic Medical Record (EMR) and the other monitor for everything else. I keep my email and DM’s open on the second monitor.
Is this distracting from patient care? Yes.
Is it necessary? Also yes.
Because, as in this case, it’s a time-sensitive matter.
The DM tells me that the appeal phone call for a denial of coverage for one of my other patients is now scheduled – for right this moment. I sigh in defeat. The insurance company doesn’t do any calls after 5:00 PM, so I can’t request to make the call after I finish with my already waiting patients. And worse, if I don’t take the time they’re offering now, they will close the appeal, and we’ll have to start over from the beginning, which will take time. Time the patient doesn’t have.
I respond that I’ll do the call, and DM my medical assistant to tell the remaining patients I’m being held up further.
From my office, I call the number for the “peer-to-peer.” After several days of work on the appeal by our hospital’s prior authorization team and me, I will finally be allowed to speak to a physician at the insurance company. However, although the term is “peer-to-peer,” in my experience, the physician I talk to will rarely be of my same specialty. I may need to explain the intricacies of oncology to, say, a cardiologist or a radiologist.
One might think that after all the time and effort to schedule the peer-to-peer call, I could instantly reach the physician on the other end. One would be wrong.
I go through a phone tree. When a person finally picks up, I give the disembodied voice the demographics of my patient and their case number. Then I’m put on hold again. After several precious minutes—in which I picture my remaining patients poking their heads into the halls to ask my staff where I am and point out how long they’ve been waiting—another non-physician voice comes on the line, only to tell me they’re putting me on hold again. Several more minutes tick by, during which I try to catch up on some charting, but the hold music is too distracting. I don’t dare try to change the volume or phone settings in case I accidentally disconnect the call.
Finally, the insurance physician picks up. I glance at the ticking digital timer on the phone base. Twelve minutes have elapsed.
I take a deep breath and calmly explain my patient’s situation and the treatment I’ve prescribed. What I’ve given up on saying on these calls is that all of this is written out in my patient’s chart in a very detailed manner, as are all my patients’ treatment plans. Physicians spend years of training on how to properly document our clinical rationale.
After discussion, the insurance company physician agrees to authorize my patient’s treatment. As is typical for most of these denials, they explain that their company didn’t greenlight it in the first place because they couldn’t find the right “checkbox” on their “approved list.” These rote lists may serve well for “common” cancers, but in oncology, especially in my rural, underserved practice, I find more patients than not don’t neatly fit the checkboxes. None of my patients are common; each is unique. An individual human being.
So when I saw the recent article by ProPublica that details how a major insurance company instructed its employed physicians to deny coverage of treatments and services without ever reviewing the medical record, I had zero surprise. My clinical experience has long led me to suspect such a knee-jerk denial of services. The insurance companies are playing a game of attrition—counting on the fact that most denials will not be appealed.
In my specialty of cancer medicine, however, it isn’t simply a matter of cost or preferring a generic brand of medication to a brand name. These are too often life-and-death situations where time is of the essence.
One thing stands out when I reflect on the hundreds of “peer-to-peer” appeal calls I’ve made over the past decade. I have never failed to overturn the denial.
It is beyond egregious that the insurance companies have been allowed to get away with this for so long. The companies don’t see the consequences of their denials or what the appeals cost us.
For physicians, appeals cost time and energy. It takes us away from other patients, who suffer the stress and inconvenience of extra waiting. And the gaslighting of our medical expertise contributes to the ongoing epidemic of physician burnout via moral injury.
For the patients who receive an initial denial, even when the appeal is successful, it causes the harm and suffering of being told their care might not be covered and wondering how they will pay for treatments necessary to save their lives. Will they face such impossible choices as selling their home and going bankrupt to afford their cancer treatment? Choosing between food or medicine? It forces them to confront the reality that our medical system doesn’t consider them inherently “worthy” of care. Even after we win the appeal, these mental harms cannot be undone.
For the past several years, out of necessity, I have a short speech I give every new patient up-front. I explain how the insurance denial process works and that they, unfortunately, may receive a letter, even before I do, that their treatment is being denied. I then end the speech by telling them not to worry; as their cancer physician, I will appeal it—and I will succeed.
It’s beyond time that our medical organizations and government stand up to these insurance behemoths the same way we individual physicians do. Before we’re all burned out and used up—and none of us are left.
JL Lycette, MD, is a hematologist/oncologist and writer in rural Oregon. Her medical perspective and narrative medicine essays can be found in NEJM, JAMA, Journal of Clinical Oncology, The ASCO Post, Medscape, and Doximity, among other places. Her debut novel, a speculative medical thriller, THE ALGORITHM WILL SEE YOU NOW (Black Rose Writing Press), is out now. See more of her writing on her website, https://jenniferlycette.com, and connect with her on Twitter @JL_Lycette