As Augie Lindmark, a resident physician at Yale University prepared for an onslaught of Covid-19 patients last week, he noticed something at his hospital: there were still patients without the virus, completely stable, in the beds.
These patients, many of whom should have been moved to a rehab facility or released, were stuck waiting until their private health insurance company authorized the next steps, which can take days.
Usually, the prior authorization process is an expected inefficiency at Yale, and most other American hospitals. But with thousands of Covid-19 patients being admitted every day across the country, and a critical shortage of hospital beds, that red tape now carries much more weight.
“Any sort of slowing in the health system has dire consequences,” Lindmark said.
In the past two weeks the reality of the Covid-19 pandemic has hit the country. States and cities have been weighing public health measures, making changes to government health plans, and pushing sweeping changes to everyday life. Physicians have largely sought to reschedule and cancel elective surgeries and other patient visits deemed non-essential to free up resources to handle the virus.
But with a history of restrictive and confusing policies, private health insurance companies have lagged behind: making incremental changes to plans even as health providers seek to change course.
“They’re doing healthcare to make money, not to take care of people,” said Dr Judd Hollander, an emergency medicine physician and associate dean at Thomas Jefferson University in Philadelphia. Hollander has been instrumental in implementing Jefferson’s telemedicine program, which allows patients to consult health providers through secure video, over the past few years.
Telemedicine, most experts agree, is an impactful and low-cost tool in slowing the spread of the virus. Telemedicine eases the burden on hospitals and hospital beds by redirecting patients without in-person needs.
Donald Trump recently expanded telemedicine provisions under the Medicare plan – a public insurance plan for senior Americans – allowing physicians to get paid equally for in-person or remote visits, and approving more devices and programs like Skype to be used to telemedicine.
But private health companies do not have to follow the same rules.
“The federal government never aligned incentives, most states never passed meaningful legislation, and many commercial payers didn’t pay health systems for telemedicine,” Hollander said. “So now we’re left in this horrible scenario.”
Several private physicians the Guardian spoke to were struggling to implement the systems from scratch as Covid-19 cases started to flood their states. Some physicians said older patient populations didn’t know how to use the technology. Others said the variations in private plans made it hard to make any new protocols without risking revenue, which could affect their employees.
“I think the issue is that private insurances have not really made it clear that they will reimburse these visits and if so at what cost,” said Dr Vipul Patel, an orthopedic surgeon in Brooklyn.
Riddhi Shah, the director of operations at a mental health clinic in Michigan, said insurance companies are hard to contact right now, and while the plans have dropped the prior authorization restrictions, the clinic still has to navigate new billing codes and financial loss.
For those who have already built telemedicine systems, the demand is clear.
As NYU Langone absorbs some of the largest populations of Covid-19 patients in the country, the telemedicine system has gone from serving 1,500 patients a month to about 3,000 a day in the past week, said Dr Shabana Khan, a child psychiatrist at NYU Langone who has been helping build the hospital system’s telemedicine capacity for the past few years.
She said many private doctors, meanwhile, are burdened by the restrictions that insurance companies have placed in the past, which made it harder for them to set up a system like NYU. She pointed out that only 10 states have true telemedicine parity, which means providers can treat and bill for telemedicine visits like in-person visits.
With the bureaucracy standing in their way, some doctors are trying to work around private insurance altogether. Sas Ponnapalli, founder of Beam Health Group, a telemedicine platform that connects patients and providers, saw 400 new health providers sign on last week. While the platform does allow private insurance, Ponnapalli said doctors are choosing to set their own rates to make the transition faster.
“Doctors sometimes have to close their doors or quarantine themselves even if they’re still able to practice,” he said. ”They want to get up and running as soon as possible because they’re losing revenue so they’re bypassing insurance completely and charging cash.”
Health insurance companies insist they have been adapting to the crisis.
A spokesperson at Humana, one of the nation’s largest insurance companies, told the Guardian it is not charging patients for Covid-19 testing, and a representative of the Association of Health Insurance Plans (AHIP) pointed to a letter signed by various private payers about their commitment to fighting Covid-19. Aetna, another leading US insurer, has waived costs related to the illness for many members. This is partly because the federal government is requiring the plans to cover all visits, virtual and not, related to testing, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, a health research and advocacy firm, who tracks the private market.
But that hasn’t stopped insurers from charging patients for other Covid-related charges. AHIP confirmed that out-of-pocket expenses for the treatment would not be waived, and could cost patients thousands of dollars. The average amount for someone admitted to the hospital with pneumonia, a respiratory condition that many coronavirus patients are facing, was $20,000 in 2018 for patients covered by private insurance, according to an analysis by the Kaiser Family Foundation and Peterson.
That could leave many people falling back on the age-old American dilemma: get healthcare or lose all financial security. And it could leave physicians finding loopholes and workarounds to stay afloat.
“Insurance companies are not beholden to the patient, they are beholden to the shareholder,” Hollander said.
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