A brash 30-year old man comes into the Emergency Department(ED) with low-grade fever and immediately demands hospital admission. Already annoyed at having made to wait (triaging rightly placed him low down on the wait-list), the patient was carefully examined by the duty doctor who then ordered some essential blood tests. Upon a few hours observation in the sick bay and on receipt of the blood test results, the doctor dutifully explained that there was no medical necessity for the patient to stay in and that outpatient treatment would more than suffice.
Whereupon, turning red in anger, he quickly whipped out his trendy mobile phone and made a call to his father who happened to be the President of a large company which used the hospital as its main referral centre. In next to no time, the hospital CEO was on the scene and the doctor’s decision was overruled on the basis that the patient represented an important client of the hospital and the hospital needed to maintain ‘good relations’. He was then admitted for investigation of fever, without much justification for in-hospital stay based on mclinical grounds. While in hospital, the patient insisted on a whole battery of expensive tests, including heart-scans, confident that this would be taken care of by his private health insurance policy. Needless to say, upon the patient being discharged, the insurance company rejected the hospital’s bills on the basis that the tests were irrelevant to the illness. Finally, the hospital was forced to absorb the costs.
Does the above story sound familiar? If you’re a hospital manager or an emergency room doctor, this incident is not unusual at all. Many a time, healthcare providers are faced with a situation like this, where there is abuse of the facilities between either one (or more) of the three main stakeholders in healthcare delivery: the patient, healthcare provider and the payor (usually insurance companies).
In this particular case, the insurance company was the winner but a similar scenario could arise when a doctor, practising extreme defensive medicine, could have ordered ‘grey area’ investigative tests at the behest of the patient. In which case, the insurance company would be the loser.
Whichever way it strikes, the ultimate loser is going to be the consumer because there’s no free lunch and everybody’s got to sing for their supper. So, the insurance premiums will keep on rising and consumers will have to dig deeper into their pockets.
Even so, insurance companies are facing huge problems containing costs, given that inflation within the healthcare industry is in double digits. Recently, more heat occurred in the Oregon summer when an elderly woman with lung cancer was prescribed a $4000 a month cancer drug and was told that ” the Oregon Health Plan wouldn’t cover the treatment, but that it would cover palliative, or comfort, care, including, if she chose, doctor-assisted suicide.”
This is clearly an ethical conflict – denying chemotherapy to terminally ill patients while offering to pay the cost of helping them die.