Making Up the Difference: Otolaryngologists find ways to provide care for under- and uninsured patients

“We didn’t look specifically at insurance status, but given that this was a typical patient population at Cook County Hospital, the uninsured or underinsured rate was probably around 70 percent,” Dr. Patel said. “A much higher percentage came in with advanced-stage disease compared to what we’d expect as a nationwide norm.”

Other studies have examined the relationship between insurance coverage and asthma control. Uninsured children with asthma are much more likely to visit the emergency department for asthma attacks than their insured counterparts; they’re also less likely to have a usual source of health care (Pediatrics. 2006;117(2):486-496). Uninsured adults with asthma typically have lower peak flow rates than insured adults with asthma; they’re also less likely to be on inhaled steroids, despite the fact that the most recent asthma control initiatives from the National Institutes of Health state that “inhaled corticosteroids (ICS) are the most potent and consistently effective long-term control medication for asthma” (J Gen Intern Med. 2002;17(12): 905-913; NIH Publication No. 10-7541. April 2010).

Otolaryngologists who care for under- and uninsured patients also report having difficulty diagnosing patients in a timely fashion. Dr. Rima DeFatta knew that her patient with possible neurologic involvement needed medical imaging, but she has tried to balance her need for accurate medical knowledge with her patient’s limited ability to pay for testing. She worries that valuable treatment time may be lost in the process.

Best Care vs. Covered Care

While otolaryngology moves toward evidence-based medicine, insurance coverage doesn’t always meet those same standards.

“Most insurance company guidelines lag so far behind the most recent medical literature and consequently require that patients fail three or four different medications and jump through several steps before they’ll approve the drug of choice. Of course, it’s also about their bottom line when some outdated generic medication is on the preferred list,” Dr. Rima DeFatta said. She reports having frequent difficulty with anti-reflux medications, such as Nexium. “Reflux of larynx has a very different pathophysiology than reflux that affects only the esophagus and stomach. The insurance companies start to apply rules as to which medications and dosing they’ll pay for, but they’re completely inappropriate for the disease at hand,” she said. As a solution, Dr. Robert DeFatta has started to attach published research papers to preauthorization requests, which he says has brought him “some success.”

Tough Choices

When insurance coverage is inadequate, both patients and providers are forced to make tough choices. “It makes things more difficult when a second-line, more specialized antibiotic is the one of choice, but it’s not covered by the plan,” Dr. Patel said. “Then we either have to ask that patient to come up with the money to pay for it or choose an alternate choice that may not be what we think is ideal.”