The patient in the exam room needed his wife and daughter to help him put his shirt back on. He was physically unable to do so by himself because he was unable to raise his shoulder high enough to do so.
My diagnostic impression made me believe that he had a rotator cuff tear and would need surgery to repair it. From past clinical experiences, I knew I could get him in to see an orthopedist more quickly if I had a MRI confirming the diagnosis rather than referring him with shoulder pain rule out rotator cuff tear.
In the past, this is indeed the way the medical course would progress and the patient would be in quickly for treatment to alleviate his suffering. But, not this time, and not many times in recent months.
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The medical treatment halted when the patient’s medical insurance company deemed the MRI as not medically necessary.
I think we all understand that insurance companies have staff hired to follow certain clinical pathways to control costs and maximize company profits. Many do not possess any medical training or even any advanced training other than a high school diploma. But, all that aside, I took the next step and appealed to medical reason, the medical director.
The insurance companies now call these peer-to-peer discussions because, in theory, we are equally educated. In the past, I have often reasoned with these medical directors to see the medical decision from my point of view.
However, there was no reasoning in this “peer-to-peer” discussion. According to company clinical guidelines, the patient had to try 6 weeks of physical therapy first and fail.
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In my mind, that equals 6 weeks of torture for a patient who cannot raise his shoulder enough to dress himself, comb his hair or brush his teeth with his dominant hand. My pleas fell on unhearing ears and in the end, the medical director explained that she was not denying care and the patient was free to pay for the MRI out-of-pocket.
Of course, the patient was currently unable to work without the use of his shoulder so had no extra money to pay for such an expensive test. The quicker he received treatment, the sooner he would be back to work and off disability.
If we disregard compassion and true medical care and go with insurance company guidelines (ie cost containment), this does not make sense either. Over time, leaving this patient untreated will cost more in terms of disability, pain medications, doctors visits, wife’s time lost to work to take care of his needs and many more.
So, who made the medical decision here?
My medical decision was to have the patient do a MRI to confirm the diagnosis and then to go on and be treated as soon as possible by an orthopedist. My decision was based on the history I gathered from speaking with the patient and from my physical examination as well as my past experience treating similar patients.
The decision here was made by the medical director based on insurance company guidelines to control costs without ever speaking to the patient or examining him. Yet, I am the one responsible for that decision. The medical director is pretty much held free from liability by contractual terms. She is free to make these decisions every day with no oversight like doctors in the trenches must face.
I ask again, who is really making the medical decisions about our patients? Shouldn’t they at least share the liability or at least bear the responsibility of their own actions like the rest of us do?
