The Cost of Health Care

Today I received a message from a patient who needed early refills of two of his regular medicines: medicines that he takes every day and has taken for years. This patient was going out of the country and needed to get his refills earlier than scheduled so he could have a full supply with him, otherwise he would run out of medications overseas. The call (taken by my staff) was a request for me to call his insurance company to request an override for an early refill. He had attempted to refill these meds ahead of schedule, but the pharmacy told him his insurance company would not pay without an override.

Much has been said/written/blogged about the cost of health care. A malpractice environment that leads to unnecessary testing, a system where the more you do the more you get paid, and the uninsured all some of the popular ones. However, recently there has been little discussion of the cost of administrative overhead.

Referrals, prior authorizations, overrides, etc. are all tools designed to deny patients care. They have been particularly useful for for-profit insurance companies who spend much more on administrative costs then government health insurances (Medicare, the VA) but don't provide better quality. The for-profits spend money on these services because health care is so expensive that the only way to make a profit is to deny patients care.

However, these administrative costs are for the insurers. What about the administrative costs to the physician? For my patient today who needed an early refill, no intervention was really needed by staff or a physician. The pharmacist should have been able to refill the medication early based upon their records. However, my staff had to spend the time to take the call and record the message. I will now have to spend the time to call the insurance company for the override. All this extra time not only takes away time from care for patients who really need it, but also increases costs. Since I am spending time doing things like prior-authorizations and referrals and not generating income from these activities (though incurring liability), I must compensate, usually by seeing more patients in a shorter amount of time. Since insurance hassles take a tremendous amount of staff time, I need to hire more staff.

Our institution is one of the largest multi-speciality practices in D.C. Our Division of Internal Medicine has about 25 providers (not all full time). We have hired four full time staff members that do nothing all day but fill out referral forms for patients so they can see the specialists that we think our patients should see. Their salaries are not paid by the insurance companies who necessitate their work, so they come from the small payments we receive from the insurance companies.

The for-profits have quickly learned that one way to decrease health care costs (and thus profit) is to deny care to patients using these methods. The extra work on the physician and their staff is not covered. As we expand health care and think about ways to cut costs, surely similar methods will be used. Any new health care system (i.e. the medical home) must not just increase payments to primary care physicians for the hard medical work they already do, but also reduce administrative burden and/or cover the expense of such burdens.