A physician writes about the healthcare insurance morass.

Good essay - not too long - in the NY Times.     "What Doctors Like Me Know About Americans’ Health Care Anger"

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?”

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.

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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.

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I’ve been on the other side of the American health insurance quagmire, too, as a patient. Recently, my primary care physician recommended I undergo 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.

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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 whims 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, and 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.