by Elizabeth Hofheinz, M.P.H., M.Ed., January 23, 2020
One spine surgeon is greatly troubled by the current reimbursement melee. And with every approval of a new product it becomes worse, he says. “These are FDA approved products,” he laments, “but so far no one has been able to reign in the insurance companies.”
Insurance Companies: “Just live with the pain.”
“I have had more than one cervical myelopathy patient denied surgery. In one case, the patient’s spinal cord was compressed, he had undergone three surgeries, the plate had collapsed, and he had a nonunion at two levels. The insurance company’s response? ‘He has lived with that for two years so he can just continue to live with it.’”
“Another patient was living in severe back pain, but because there was no xray-documented instability the insurer refused to cover it.”
“I recall two cases of myelopathy where weakness was the core symptoms and the MRI clearly showed a signal change. But, the insurer got hold of a 4-year-old MRI that had a fairly similar signal change and they then denied the surgery. We did fight it in both cases and were successful.”
Incontinent? Too late…
“Some say that if the patient is incontinent, then it is time for surgery. That’s crazy. It’s like saying someone has to be paralyzed before we can do surgery. This situation is particularly bad for those suffering with back and neck because it greatly affects one’s quality of life. This just kills surgeons as we are all about restoring function and quality of life.”
Banking on patients and doctors not fighting the system…
So what does this surgeon tell his patients? “I tell patients that we will advocate for them, but that they have to do the same. Insurance companies are essentially betting that neither patients nor doctors will spend the time and energy to fight their initial decisions. Their thinking is, ‘Hey, if we refuse 100 people maybe only 20 of them will challenge us and hey, we’ll probably not have to cover about 80 of them.’”
“Peer” review…yeah, right
“As it is now,” says this surgeon, “if a case needs to be reviewed, the insurance company sets up a medical panel…but, the problem is that it is largely 70-year-old retired physicians from any background (hematologists, etc.). That is hardly a peer review.”
“Insurers need to disclose what they are paying physicians and what they are paying the hospital so that the patient has a choice. They see the charges, which are inflated. And patients are largely in the dark on many things, including, for example, what deals insurers make with hospitals.”
So, who is going to reign in these powerful companies?
“We need a major political change in order for these companies to be held accountable.”
“Ideally, our specialty societies would offer a panel of surgeons who can review cases for the insurers. That way, a gynecologist won’t be deciding who needs a spine surgery.”
