Opinion

Patients, Not Profit Margins, Need to be Insurers’ Priority

It seems like an easy question: Do you want your doctor to provide the best medical care for you? It should be that easy, but apparently, it’s not.

As a longtime advocate for cancer patients, I have often helped them battle insurance industry bureaucracy for the treatments and coverage they needed. I always asked one simple question of the insurance executive or medical director: “If this was your mother, your son, your best friend — wouldn’t you want them to have the very best treatment?”

I always felt it was important to put a face in the conversation, which otherwise could easily get bogged down by sterile discussion about insurance policy design and coverage. Often, that question went unanswered, and it was clear the patient’s care was not the priority.

When I recently read the stunning admission by a former medical director of Aetna, one of the nation’s largest health insurers, that he never reviewed a patient’s medical records when deciding whether to approve or deny claims, I can’t say I was surprised.

In fact, I’m surprised it took so long for such an egregious act to be exposed and for a light to shine on health insurers and their process for determining what is best for patients.

And if you’ve been through the grueling experience of trying to get a treatment or medication approved by your insurance company, you’re probably not surprised, either. Likely, you were told your recommended treatment or medication wasn’t medically necessary, wasn’t medically justified or wasn’t in-network. If you didn’t have a really savvy support system behind you or the time to fight these paperwork and phone call battles, you very likely gave up and settled for different care than you wanted or paid more to go out of network.    

If that’s you, then you’re not alone. In fact, state insurance and health care officials everywhere should be asking how many patients out there have been harmed by sloppy reviews and incompetent decision-making by insurance companies.

Those of us who advocate for patients know how damaging the system can be. Action is long overdue for patients to get the insurance benefits they pay for and deserve.

I hope this breathes new life into all of you who have been defeated by insurance companies. Recently, a hashtag helped bring change to a part of society that has desperately needed change, and it brought victims the courage to speak up. This news makes me wonder if we should all come together and ask #whatsinsurancefor?

Instead of allowing insurers to obfuscate patient and physician requests for timely and high-quality care, maybe it’s time for real public outrage that demands more accountability and transparency on how insurance determinations are made.

It’s a wonder it’s taken this long. Thirty-three years ago, I began my career in the health care field, working to implement insurance programs at physician practices and then overseeing insurance contracting for one of the nation’s most prestigious cancer centers. I saw firsthand the denials of patients’ needs and the frustration from physicians, patients and their families because they simply could not access the care they needed. And they didn’t know why.

Let’s demand change. If you’ve been denied coverage or care by your insurer, tell your story. Tell it to your state’s insurance commissioner, your state’s attorney general, your local legislator – anyone who will listen. Let’s demand that all insurers make coverage determinations based on the best interests of the patient, not their profit margin. Let’s demand that insurers have clinical experts reviewing physician and patient requests to provide fair and unbiased opinions.

And let’s make sure that patients get the care we would all want for our mothers, sons and best friends.

Patricia J. Goldsmith is chief executive officer of CancerCare.

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