Doctors’Dilemma: Caught Between Patients and Insurers

Between a rock and a hard place

JC is an active, 50 plus year old male who was gardening outdoors when he was stung by a yellow jacket. Within 15 minutes, he got dizzy and collapsed. His family called EMS and the paramedics arrived 5 minutes later and injected him with epinephrine and started IV fluids. He was transported to the nearest ER where he got more IV fluids, steroids, and Benadryl. He was observed in the hospital overnight and discharged with an epinephrine autoinjector and a referral to the local allergist. He saw the allergist and one month later was found to be allergic to yellow jacket, wasp, and hornet venom and started venom allergy injections which would protect JC from any further episodes of anaphylaxis for the rest of his life.

A simple happy ending, right? Wrong! Unfortunately, medical care in this country is no longer that simple or straightforward. For some reason only known to itself, JC’s insurer decides to cut payments for venom allergy injections down to half of acquisition cost (meaning half the price of buying the venom from the manufacturer, not even including the price of needles, syringes, alcohol pads, and the nurse giving the injection). Calls are made and letters are written to medical directors, without avail. This now puts JC’s doctor in a bind:

How can you continue providing a service or a product when you are losing money on that service/ product?

The answer is, you can’t. Bakers stop making cakes, carmakers stop making cars, shops close down. And yet, this is not just a cake, or a car, or a shop. This is JC’s health and life.

JC’s insurer is playing games with patients’ health care. It doesn’t want to get the rap for not covering a very important therapeutic intervention, BUT it doesn’t want to pay for it either. So, who gets left holding the bag? JC’s doctor, for now. But since you can’t continue practicing at a loss, eventually JC and all the other patients will not have access to this therapy, even as they religiously pay their insurance premiums every month. This scenario is seen in slightly different settings all over the country, from chemotherapy and vaccinations, to mental health services.

Patients deserve good health care and doctors should not be penalized for practicing good medicine. Insurers should be helping patients and physicians, not making it more difficult. Stop playing games, or we all lose.

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