Opinion, Guest Essay By Helen Ouyang
Dr. Ouyang is an emergency physician and an associate professor at Columbia University.
I rushed around the patient as he lay motionless with his eyes closed in the emergency room. He was pale and sweaty, his T-shirt stained with vomit. You didn’t have to be a health-care worker to know that he was in a dire state.
The beeps on the monitor told me his heart rate was dangerously slow. I told the man that he was going to be admitted to the hospital overnight.
After a pause, he beckoned me closer. His forehead furrowed with concern. I thought he would ask if he was going to be OK or if he needed surgery — questions I’m comfortable fielding. But instead he asked, “Will my insurance cover my stay?”
This is a question I can’t answer with certainty. Patients often believe that since I’m part of the health-care system, I would know. But I don’t, not as a doctor — and not even when I’m a patient myself.
In the United States, health insurance is so extraordinarily complicated, with different insurers offering different plans, covering certain things and denying others (sometimes in spite of what they say initially they cover). I could never guarantee anything.
I didn’t say all this to the man, though, because I needed him to stay in the hospital and accept inpatient treatment. So instead I hedged. “You’re very sick,” I told him. “You shouldn’t worry about your insurance right now.” I should have been able to give him a better answer, under a better system.
The killing of Brian Thompson, the chief executive of UnitedHealthcare, the country’s largest health insurer, has reignited people’s contempt for their health plans.
It’s unknown if Mr. Thompson’s tragic death was related to health care, and the gleeful responses have been horrifying. But that reaction, even in its objectionable vitriol, matters for how it lays bare Americans’ deep-seated anger toward health care. Around the country, anecdotes were unleashed with furor.
Among these grievances is the great unknown of whether a treatment recommended by a doctor will be covered. It’s critical for me as a physician to build trust with my patients by giving them clear answers. But the conversations we’re seeing now about health care remind me that insurance unknowns don’t just compromise the care I can deliver to my patients — they also undermine the fragile doctor-patient trust. It’s an unsustainable dynamic.
Unsurprisingly, despite my platitudes, my patient did worry. Instead of resting on the stretcher, he and his wife began calling his insurance company. To keep him from leaving, I tried to be more persuasive, even though I didn’t know what kind of health plan he had:
“I’m sure your insurance will pay. I’ll document carefully how medically necessary this admission is.” I added that social workers and other advocates could also assist in sorting out his insurance once he was admitted. And, worst-case scenario, if they couldn’t, I crossed my fingers that the hospital’s charity care would help.
I said what I could to get him to stay, but I understood why he wanted to be certain. The average cost of a three-day hospital stay is $30,000. He had heard the health-insurance horror stories. Maybe he had lived through one himself.
One of my first lessons as a new attending physician in a hospital serving a working-class community was in insurance. I saw my colleagues prescribing suboptimal drugs and thought they weren’t practicing evidence-based medicine. In reality, they were doing something better — practicing patient-based medicine. When people said they couldn’t afford a medication that their insurance didn’t cover, they would prescribe an alternative, even if it wasn’t the best available option.
As a young doctor, I struggled with this. Studies show this drug is the most effective treatment, I would say. Of course, the insurer will cover it. My more seasoned colleague gently chided me that if I practiced this way, then my patients wouldn’t fill their prescriptions at all. And he was right.
I’ve been on the other side of the American health insurance quagmire too, as a patient. Recently, my primary care physician recommended that I have additional testing to assess my risk for certain diseases. The patient in me instinctively asked if my insurance covered it, even though I knew she wouldn’t know the answer. “They should,” she said. “It seems most insurers are paying for it.” I recognized her response — it’s the same optimistic but vague one I often give.
When doctors can’t give a straight or accurate answer, patients may lose faith in them.
What’s more, when insurers reject claims, they usually blame the provider — the medical code used was wrong, the diagnosis wasn’t specific enough — which can further erode the relationship between patients and their doctors.
I saw this happen with my mother. She got her annual flu shot, which is part of her preventive care — a proactive step we want patients to take — but her insurance said it wasn’t covered because her doctor supposedly used the wrong code.
The clinic resubmitted the claim, but it continued to be denied. Each time my mother called her insurance company, an agent blamed her doctor. Eventually, my mother grudgingly returned to her physician for her annual exam, but her relationship with the primary care practice has frayed. She also no longer gets her vaccines there.
My one family member with solid insurance is my dog. He got elective surgery recently, and I was astounded by the straightforward nature of his insurance. Once we meet the deductible, everything is simply covered by 80 percent. This is clearly described in a packet I received when I first signed him up. It’s an imperfect comparison to insurance for humans — I pay in full first, then get reimbursed — but it’s incredible to think that insurance for pets and possessions is easier to navigate and more consumer-friendly than insurance for people.
The country is not heading toward a single-payer system, but that doesn’t mean we have to continue leaving patients and their doctors in the dark. I loathe the fact that patients can’t automatically get the care they need without thinking about costs. But they at least deserve clarity about what’s covered before they acquiesce to expensive tests and treatments.
Health insurance shouldn’t be so opaque, up to the whim of different companies. Coverage shouldn’t be so convoluted, mired in rigid codes and obfuscating wording. I should be able to tell my patient in the E.R. if his hospital stay will definitely be paid for. I know exactly how much of my dog’s care will be covered; why can’t I know the same for my patients?
In the end, my patient in the E.R. decided to go home that day. I reiterated how sick he was. I showed him the results that concerned me, even tried to tell him that he could possibly die if he left the hospital. But I’m not sure how much he trusted me after my overconfident assurances that his insurance would pay; when he finally got through to an agent, he was told coverage would depend on the specifics of his care.
He couldn’t risk a big hospital bill right now, he told me, matter-of-factly. He promised to come back if he felt worse.
Helen Ouyang (@drhelenouyang) is a physician, an associate professor at Columbia University and a contributing writer for The New York Times Magazine. She is also a fellow at the Type Media Center.
