Doctors Rima and Robert DeFatta, married otolaryngologists who work at Sacred Heart Hospital in Eau Claire, Wisconsin, spend about an hour each day dealing with insurance-related hassles. About 20 percent of their patients are un- or underinsured, so the two physicians spend time dashing off letters to insurance companies, re-jiggering treatment plans and helping patients access available resources. Recently, Rima DeFatta, MD, had to figure out how to diagnose a patient who presented with symptoms that suggested possible neurologic involvement.
“My patient only has major medical coverage, so I’m trying to figure out how to accomplish accurately diagnosing him with studies that may not be optimal to diagnose his pathology,” she said. Her husband, Robert DeFatta, MD, PhD, works with head and neck cancer patients; he’s often frustrated by insurance companies’ refusal to pay for effective pain medication or to cover cancer-preventing vaccines.
Their experience is not unique. According to the Kaiser Commission on Medicaid and the Uninsured, there are close to 50 million uninsured Americans. Millions more are underinsured, and the lack of adequate insurance is affecting care. A recent study of 155 patients who discontinued treatment for allergic rhinitis revealed that 40 percent discontinued subcutaneous allergen immunotherapy due to inadequate or nonexistent insurance coverage (ENT J. 2011;90(4):170-173). Other studies have correlated poor asthma control with lack of adequate insurance (J Gen Intern Med. 2002;17(12):905-913; Pediatrics. 2006;117(2):486-496).
Recent government reforms, most notably the Affordable Care Act, are meant to address the growing problem of un- and underinsured patients, but it “remains unclear if government solutions are going to be either effective or lasting in terms of solving the problem,” said Urjeet Patel, MD, associate professor at Northwestern University and chair of otolaryngology at Cook County Hospital in Chicago. In the meantime, individual otolaryngologists are left to figure out how to provide quality care to patients who may not be able to afford it.
Access to Care
Lacking comprehensive insurance, many patients forgo routine physicals and preventative care. As a result, otolaryngologists may see more patients with advanced disease. Dr. Patel, who sees patients at both Northwestern University and Chicago’s Cook County Hospital, has noted that head and neck cancer patients who present to Cook County, a publicly funded institution, tend to have more advanced disease than those who present at Northwestern. In one study of 209 patients, 68 percent of the head and neck cancer patients at Cook County presented with Stage IV disease; 16 percent were Stage III (Laryngoscope. 2006;116(8):1473-1477).
“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.”
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.”
Often, patients make tough choices in the privacy of their homes. One study found that 18 percent of surveyed chronically ill adults had at least one episode of cost-related medication underuse in a year. A full 20 percent of patients with asthma reported under-using their asthma meds to save money; 18 percent of patients with heartburn cut back on their reflux meds (Am J Public Health. 2004;94(10):1782-1787).
How to Help
Despite the obstacles, otolaryngologists nationwide are stepping up to care for un- and underinsured patients. These tips can help you improve care for your insurance-challenged patients:
- Talk about it. “Many physicians have a ‘don’t ask, don’t tell’ policy in terms of whether or not their patients are filling their medications or can afford to fill them, said Lane Johnson, MD, author of The Care of the Uninsured in America (Springer, 2009). “Don’t put your head in the sand. Really ask a patient whether he thinks he’ll be able to afford the medication.”
- Use samples judiciously. Sample medications can be used to get patients through an acute crisis, such as a sinus infection, said Dr. Robert DeFatta. Sample medications may also be “useful when we’re trying to initiate therapy,” Dr. Patel said. “They essentially provide a low-cost or no-cost approach to try something and confirm that it works.” The problem, though, is that many patients won’t be able to afford the medication when they run out of samples, leading to a possible gap in treatment.
- Connect patients with pharmaceutical company patient support programs. If you often prescribe expensive medications that are not well covered by insurance, find out what kind of help is available from the pharmaceutical company. “Most pharmaceutical companies have patient support programs,” Dr. Johnson said. “If the patient is willing to fill out the forms, usually about nine to ten pages worth of them, and you send them in on their behalf, they can get medications for free.” (For more information, see “Free & Reduced Fee Medications.”)
- Provide evidence. Both Dr. Rima and Dr. Robert DeFatta have had some success securing insurance coverage for certain medications or procedures by sending additional documentation to insurance companies, including journal articles that demonstrate the validity of their choices.
- Talk to local pharmacies. Many will be willing to establish some kind of discount or payment program for un- and underinsured patients. Encourage patients to shop around also. A lot of price variety can be found in the same town.
- Improve patients’ insurance status. “We see many patients who are uninsured but who might actually be eligible for Medicaid or public aid,” Dr. Patel said, noting that unfamiliarity with the English language or medical system may keep patients from independently obtaining insurance. Refer un- or underinsured patients to hospital social workers or community agencies who can connect them with benefits. One study found that enrolling eligible children in New York’s State Children’s Health Insurance Program (SCHIP) drastically improved asthma care; the percent of unmet health needs dropped from 48 percent to 21 percent, and hospitalizations decreased from 11 percent to 3 percent (Pediatrics. 2006;117(2):486-496).
- Know what’s available in your community. What kinds of free clinics, health screenings and faith-based clinics are in your community? Seek out the resources around you, and compile a list to present to your patients. Look for federally funded healthcare centers (search via zip code at findahealthcenter.hrsa.gov) and community and migrant health centers (ncfh.org). Reach out to your county’s public health department to see what services are available. Call your local houses of worship. Do any offer free- or reduced-price health care in partnership with local hospitals or clinics?
- Consider discounting your fees. “I think that all physicians have a responsibility to provide some care to patients who wouldn’t otherwise be able to afford it,” Dr. Johnson said. Consider partnering with a free clinic to see X number of patients per month, gratis, or set up a sliding scale at your office. You might also want to offer an installment plan that is “affordable and transparent,” Dr. Patel said.
- Advocate for the care of un- and underinsured patients. Ask your hospital to consider covering a certain number of surgical procedures per month. “Tell them, ‘Let’s figure out how we can work this out so the patient can get what they need,’” Dr. Johnson said. “That coming from a specialist parlays a lot more weight than it does coming from a social worker or outside agency.”
Dr. Johnson said he knows of a few situations in which this approach has worked and noted that most hospitals have charity care policies.
“It is also dependent on the personality, demeanor and approach of the advocate. One can catch more flies with honey than with vinegar,” he said.