IGNORING THE DOCTORS' ORDERS

Investigative Reporters and Editors, Inc. The IRE Journal, Winter 2009 by Eder, Steve

Survey shows physician concerns about insurance company tactics

Millions of Americans with health insurance find that when disease strikes or a new treatment arrives, their insurance lets them down - denying or delaying treatment prescribed by their doctors.

While politicians, policymakers and academics debate ways to expand insurance coverage to those without it, most have overlooked the problem of the "allegedly insured." Their plight became the focus of "Not What the Doctor Ordered," a 2008 investigation by The Blade. Our mission was to show readers - through stories, photographs, videos and interactive graphics what happens when they leave doctors' offices and why so often insurance companies reject physicians' plans.

The project began in late 2007 after sources with ties to the health care industry laid out claims that insurers were increasingly using new and aggressive methods to interfere with the doctor-patient relationship. Some physicians and patients must now deal with mountains of denials, delays and red tape.

In August 2008 we published a four-part series showing how doctors are routinely stymied in treating patients because insurers stand in the way. And most importantly, we showed how men, women and children across the country are being harmed when insurers block decisions made by medical professionals.

Surveying the doctors

The investigation, co-authored by Blade health reporter Julie M. McKinnon, included interviews with about 100 doctors in a dozen states and a nationwide online survey of physicians that garnered 920 responses.

The interviews with doctors often led us to patients who, along with their families, illustrated how people are harmed when insurers interfere with doctors' treatment plans.

The Blade introduced readers to Randy Steele, a 64-year-old man from Oak Harbor, Ohio, with hepatitis C who waited weeks to learn whether his insurer would cover a potentially lite-saving kidney-liver transplant.

We met children in Ashland, Ohio, suffering from behavioral disorders who terrorized their families and classmates when their Medicaid insurers wouldn't pay for their prescriptions.

And Peter Tsiknis, an 18-year-old from Bridgeport, Conn., shared his story about waiting nearly a year before his insurer would cover a surgical procedure to remove his abnormally large breasts that resulted from a hormone disorder. His surgeon had insisted that his condition wouldn't change without an operation.

Doctors shared their frustrations of knowing how to heal patients but being unable to get them the medicine or treatment that they needed. Some doctors were reduced to tears as they spoke about the struggle.

Aside from dramatic life or death stories, doctors spoke about the difficulties in ordering common tests such as colonoscopies and MRIs for patients who they believe would benefit.

Doctors repeatedly said the insurance company intrusions into the exam room were eroding the doctor-patient relationship.

The sentiments shared in interviews mirrored the results of the online survey, which was sent electronically to members of the Ohio State Medical Association and later to members of the American Medical Association. Although not scientific, it provided a glimpse into the scope of the frustration and problems.

The survey revealed grave concerns among doctors about their ability to effectively treat their patients:

* Ninety-five percent of respondents said insurers interfered with decisions about prescriptions, 91 percent with testing, 74 percent with referrals and 69 percent with hospitalization.

* Eighty-six percent said interference compromised patient care, 76 percent said it adversely affected their patients, and 65 percent said they were unable to successfully protest denials.

* Seventy percent noted that they experience interference at least once a week, with 92 percent saying that interference has increased during the past five years.

* Fourteen percent believed interference from an insurer had contributed to the death or serious injury of a patient.

Building the investigation

In the initial stages of reporting, I set out to interview as many physicians as possible, looking to tap into the stories of doctors in all demographics: urban and rural, solo practitioners and members of groups, specialists and primary-care physicians, new doctors and experienced ones.

Regardless of where I went, I started with a variation on one question: What's the biggest problem facing your practice? The responses shared a familiar theme as doctors again and again said they repeatedly found themselves at odds with insurers.

Along with Blade investigative editor Dave Murray, we decided then that it would be prudent to find a way to quantify doctors' feelings about insurers. We settled on a survey.

To reach the largest number of doctors, we took a unique step and decided to cooperate with the Ohio State Medical Association, an interest group that lobbies for physicians in Ohio, to electronically send the survey to its members.

Our joint agreement made it clear that The Blade would write the questions and have unfettered access to the responses. We would conduct our own analysis and publish the results regardless of the findings.