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 Lonnette Harrell

In an effort to reduce health-care expenses, (and to increase profit), insurance companies are attempting to control doctors with outrageous restrictions, according to the online Boston Globe, (Boston.Com).  

Recently, my mom was prescribed a drug, Namenda, for some memory and confusion problems. She had previously tried Aricept, but the side effects were just too horrendous– violent nightmares, uncontrollable stomach upsets, and night sweats (to name a few.) The diabetes specialist, (not an M. D.),who is employed by my mom’s internal medicine doctor, did some mini-mental assessments on my mom, and found that she had problems drawing the time requested on a clock face, (as the internal medicine doctor had also discovered when he tested her.) So the diabetes specialist mentioned to my mom that there was a new drug now available, and immediately left the room to get her a sample card. The medication was to be taken daily, gradually building up to 2 pills a day, at 10 mg each. We were given a prescription for 5 mg and one for 10 mg, depending on how she was able to tolerate the medicine. She faithfully took the samples, and worked her way slowly up in the dosage amount, without any apparent unbearable side effects. At that time, we took her prescription to be filled, just as the samples were running out. We were then informed that she would require further approval from the insurance company, in order to be able to purchase the Namenda.

This left us in a quandary, as we remembered something similar happening with the Aricept, and my mom was left waiting about 10 days. I remembered that the diabetes specialist had told me, that if that ever happened again, I could request more samples in the interim. So we quickly obtained more samples.

Today my mom received a request from her insurance company, (Blue Cross Blue Shield of Florida), to please provide a written release, authorizing her doctor to give them copies of her medical records for the last year, including diagnoses, tests, treatments, and documentation of any improvement. This led me to believe that they were going to “Big Brother” their way right into the middle of my mom and her care providers. The care providers will (no doubt) have to argue their case that my forgetful, confused, bereaved mom really needs this medication. Who knows what the insurance company standards are? And who knows how much longer this “investigation” will take?

Insurance companies have entirely too much authority, power, and control these days. I have heard numerous stories of doctors being harassed, concerning the tests they have ordered for their patients, and even for scheduling appointments too close together. Since when did insurance companies obtain medical degrees? What gives them the right to say what test, medication, or appointment is needed?

Many conscientious, caring doctors are being forced out of their practices, or are retiring early, because of the ridiculous restrictions placed on them by insurance companies, and the mountains of hoops and red tape required to procure patient insurance coverage for necessary treatment. And even worse, there is a rising physician shortage in family practice and internal medicine in many cities. Physicians entering the field, are not willing to put up with hours and hours of paperwork, and interrogation from insurance companies. They are choosing higher paid (and hopefully, less hassle) specialty practices.

One exasperated doctor is Stephen A. Hoffmann, who has admitted breaking the rules, in order to give proper patient care.  One of his patients, (a recovering alcoholic), was having great difficulty sleeping. So he prescribed a daily dosage of Lunesta–30 pills per month.  Tufts Health Plan then cut the allowable amount of pills to 10 per month. This exasperated both the patient and the doctor. The patient was the family’s primary wage earner, and Dr. Hoffmann was concerned that her sleep problems could result in a recurrence of her alcohol dependency. His solution was to prescribe a second prescription in her husband’s name, which would allow her to get 10 more pills a month. Hoffmann realizes that he could face disciplinary actions, or possibly even criminal charges, but he calls himself a “medical conscientious objector” who believes in the best interests of his patients, more than the unreasonable policies of an insurance company. He has violated prescription regulations approximately 10 times in the last six or seven years, for similar reasons. He explains that many of his colleagues are “demoralized, angry and frustrated.”

Hoffmann is not even remotely a rebel. In fact, he is a member of the Massachusetts Medical Society’s ethics and discipline committee. So his alternative solution is no small risk, knowing that he could be charged with insurance fraud, larceny, and writing a false prescription. In the past, he has lost appeals over similar matters, and fears that his patient’s health could deteriorate, while waiting for the long drawn out decision.

Many doctors are finding themselves having to answer to insurance companies for the number of days a patient can remain in the hospital, the type and amount of tests they can order, the surgeries they can perform, and even for their use of name brand drugs instead of generic. In short, medical insurance companies are able to dictate to doctors, the type of care they are allowed to give their patients (based on a higher profit margin for the medical insurance bureaucrats), and there is something very wrong with this picture. Many companies use computerized rating systems for physicians, that amount to “data-driven surveillance.” Doctors are compared with their peers in the community, and also against guidelines created by organizations such as the American Heart Association. The ramifications are costly, with the possibility that an inferior rated doctor could be closed off from an insurer’s preferred network or demoted to a lower tier in rank. Others may discover that their patients have to pay higher co-payments. (And the results of the data are often posted online.)

I love an article that I read, in the, that questioned where the line is drawn between “responsible oversight and outright meddling” concerning doctors and their patients. Simply cutting costs does little to create quality care.

United Healthcare in Washington has a Web site that ranks doctors on a scale of zero, one, or two stars, with the rating being based on collected data. The company says their desire is to “provide information to consumers, and to help doctors improve their performance.” But doctors don’t see it that way, and are loudly complaining. Legal action has been threatened by New York Attorney General Andrew Cuomo, resulting in the company delaying its data service in New York, New Jersey, and Connecticut.

There have been numerous innacuracies in the data collection, and doctors who requested to see their reports, found that they had been demoted by Regence BlueShield, for things that made no sense–like not performing a pap smear (on a lady who had a hysterectomy), and failure to control diabetes (in a patient who was not diagnosed with the disease.) Six doctors and the Washington State Medical Association, sued Regence Blueshield, on charges of defamation and deceptive business practices. Regence eventually gave up, and abandoned its plan.

One doctor in Health New England’s rating system, went from the top ten per cent of physicians, into the second (lower) tier, because his patients didn’t comply with his prescriptions for mammograms or Pap smears.

There’s no question as to why some doctors have had enough. Micromanagement by an insurance company is hardly what they signed up for. To borrow a partial phrase from a recent political candidate, “The U. S. medical system is broken.” On that we can all agree. (We just can’t seem to agree on how to fix it…)

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  1. Some year back when there were no HMO’s I can recall my corp. insurance bill increasing by 30% for a few years in a row. That’s when there were no price negotiation arenas for insurance companies and medical service providers. The HMO concept was in response to those huge cost increases. It was an attempt to get costs under control and try to keep medical expenses affordable.

    Also note that doctors participating within an HMO concept is completely voluntary. If a doctor or hospital does not want to be held to a set of standards, and thus charge whatever they want, he or she or institutions just do not participate. Granted they reduce their marketplace, but it still is a choice they can make.

    Finally, health insurance purchasers do not have to buy HMO or network products. There are still policies out there that provide coverage under non-network circumstances. There are still some rules, but the buyer can go to any medical provider they decide to use.

  2. Hi John: Thanks for your comment and the information. I see that you are an insurance agent.
    While I agree that some restriction can be a good thing (particularly in the area of exhorbitant hospital charges), the issue I am most frustrated with, is when patients aren’t able to get coverage for necessary treatment, tests, or medicine.
    While I am sure that there are some doctors who abuse the system, as a general rule, I believe that a doctor still knows best what treatment a patient needs. If we start letting insurance companies continually get in between the doctor and patient, less than adequate treatment will be given. Some deaths also occur when patients cannot get needed procedures, medicine, or surgeries.
    I am not really for universal health care because the standards are so low, when there is no real incentive for doctors. I also feel that it hasn’t worked in the countries that have that type system. I’ve heard that it can be as long as a year to get necessary surgery, and that the waiting lists for appointments are unbelieveable.
    So, I actually favor private insurance when it doesn’t micromanage the doctor-patient relationship. I think some of the caps on what doctors can charge should be in place. Again, my biggest frustration is when patients are not allowed to get necessary treatment and medicines that should be covered by insurance.
    Thanks again for your point of view! Lonnette

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