Published on
the San Francisco Chronicle

Doctor Pushes Back Against Insurer Scrutiny

Victoria Colliver

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

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.

Raising awareness

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.

Learn more

For more information about Stop Practicing Medicine, visit cfm.


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