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Doctor Pushes Back Against Insurer Scrutiny
MONTEREY, Calif - Monterey physician Bradley Carpentier found himself spending so much time fighting with health insurers to get approvals for the treatments he prescribed for his patients that he decided to wage his own lobbying effort.
Carpentier formed a new political action committee - Stop Practicing Medicine - to target the long-standing practice of insurers hiring doctors to review physician decisions, even though the insurer-hired doctors had never seen or talked to the patient whose care they were scrutinizing.
Insurers defend the practice, saying such doctors often serve as a second set of eyes to ensure patients are receiving the most appropriate and effective treatments. But Carpentier, along with patients and other doctors who support his position, says insurers are denying and delaying care.
"We need to let the doctor take care of the patient," said Carpentier, who specializes in pain management. "Pretty much, doctors ultimately do what they want, but it just depends on fighting a lot to get that done. What we've found is fewer patients have access to care in general because we have limited resources. We're being kept so busy fighting and advocating for patients."
Health insurers and doctors have long battled over care decisions, with insurers serving as gatekeepers to set guidelines and control health costs and physicians bristling at being second-guessed and overruled. The tension reached fever pitch in the 1990s when managed care was at its height, prompting a consumer backlash that led to reforms and less restrictive forms of coverage.
But Carpentier said he's seeing an increase in pushback from health plans, prompting him to refuse most insurers and, instead, treat his patients and submit reimbursement forms on their behalf. He formed Stop Practicing Medicine, he said, to raise awareness of insurance interference as lawmakers and the Obama administration begin efforts to overhaul the health care system. The organization began recruiting patient and physician members last month.
"The prospect of health reform in this particular time in history is what led me to speak out," he said, adding he is calling for restrictions of the practice but not the abolition of health insurers. "I think there is absolute change in the air and we want it to be for the better."
In poll results released last month of 389 California doctors, 87 percent described limits and restrictions that insurance companies place on doctors as a major problem.
The survey, conducted by a Seattle research firm for the California Medical Association, found 84 percent felt pressured to change the way they treat a patient because of a restriction from an insurance company and 86 percent admitted selecting a course of treatment they might not otherwise have chosen because of the pressure.
But insurer groups contend the interests of physicians and health plans are more closely aligned than ever, and that the two groups are working together on many issues such as rewarding physicians for quality rather than just quantity of care.
"It's in everybody's best interest to make sure the patient is getting the right health care treatment in the right place and in the right time," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, a national trade group. He cited studies that have shown patients often don't receive the best care supported by scientific evidence.
Protections in place
California's independent medical review system allows a panel of physicians to resolve disputes between patients, doctors and insurers, said Charles Bacchi, interim president and chief executive officer of the California Association of Health Plans.
"We just believe the most important thing is that the patient is receiving the right care," he said. "And we think there are protections there for consumers already."
Dr. Michael Leong of Los Gatos, who works with Carpentier and at Stanford University, said pain management specialists are particularly vulnerable to insurance hurdles because pain is less quantifiable that other maladies and often requires highly individualized therapies or newer, more expensive drugs.
Leong said he recently saw a patient whose neck pain had flared up, but he was unable to give her an injection she receives several times a year. That's because the insurance company requires him to submit the same paperwork and go through the same authorization process each time, he said.
"I know it will get covered in two or three weeks, but that's another two or three weeks of pain," he said.
Noel Ortiz of Twain Harte (Tuolumne County), one of Leong's patients, said she regularly had to battle her insurer until she was able to manage her pain without drugs after undergoing treatment through a clinical trial. She said she has been on the hook for as much as $15,000 in medical costs while she fought for reimbursement.
The 50-year-old Ortiz, who suffered from lower back pain from years of teaching horseback riding and training horses, said she still doesn't rest easy. "I do keep an account for fear it will happen again," she said.
For more information about Stop Practicing Medicine, visit www.drcpainmd.com/giving. cfm.