Health Insurance: America’s ‘chaotic deal with the devil?’
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Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
What challenges do doctors and their patients face when it comes to giving and receiving quality health care in America? To find out, we spoke to Dr. Nancy Niparko, a pediatric neurologist who works for Children’s Hospital Los Angeles.
Welcome to Code WACK!, Dr. Niparko.
Q: So what is it like as a physician dealing with different health insurance companies?
Niparko: Just like they will refuse payment to a doctor for seeing a patient, they refuse to the doctor the ability to order the best medicine or treatment without a lot more work and validating it and still you can’t get it. In fact, I do a clinic on Saturday, I see about 15 patients and I will say, almost every single one of them, I spent a good part of the medical visit, talking about what was rejected, and trying to think up other things that might help their child.
I can pick out the best treatment, and even be conservative about it, not the strongest medicine but something that should work, or different tests and they get rejected. Insurance just won’t cover it. I totally resent medical insurance companies. I’m in the position that I think medical insurance companies have no right to exist.
Q: Wow. How else does our multi-payer health insurance system affect you day to day?
Niparko: I mean the last few hours… I spend my weekends working on these complicated medical notes and one of about a dozen that are sitting in my inbox of a little girl who has been to one or two other neurologists and she’s tried — not little, (she’s a) young teenager — she’s tried like five or six medicines and each of them gave her some side effects or she says didn’t work for her migraines and I just want to give her the safe, effective nasal spray to work. And, of course, the insurance company says you can’t do that, and I will tell you that same medicine in the early 90s — so that’s 20 years ago — I would give it to five and six-year-olds in the emergency room and it would get rid of their headaches in a few minutes. So it’s stuff we know works been around for a long time. I’m not doing experimental medicine, but a medicine that cost pennies, decades ago is now hiked up to prohibitive costs. I prescribed it for people, and yes there are people who get it for $5, but that’s rare.
And I have people coming back and tell me it’s $900 or $2,400 for eight doses. There’s no rhyme or reason to this. It is all a chaotic deal with the devil. Today it’s different than yesterday. And it changes constantly. So the poor help — the nurses and office staff, they’re just dealing with this all the time. Patients get mad. They want to complain to me. I can’t do anything about it. We’re spinning our wheels as fast as possible, but things just keep getting rejected and patients blame the secretaries, the nurses, the doctors, the hospitals, and really it’s the insurance companies, and the drug companies are not innocent either.
Q: So why do these rejections happen? Is it simply to save money?
Niparko: Well, the people making these rules are doctors who just left medical practice, and they want to make a good salary, 9 to 5, rejecting other doctors requests, and they’re not a specialist in my area, but they decide what medicines I can use. They’re just rejected. They’re not on formulary, that’s the term. They’re not on formulary. So they make a list of medicines that are allowed, and they’ll have different lists some costs more copay than others and they’re really not according to how effective they are, or how much they’re needed. It’s really about who they’ve been able to make deals with — what drug companies do they have deals with that they can get lower prices for.
Q: Got it. Do you have a specific example of this that you can talk about?
Niparko: So for instance, I know that these nasal sprays stop headaches more completely, not only quicker, but more completely so your brain can heal, but the nasal sprays are uniformly rejected by most insurance companies and I should just give up prescribing them but I hate drugging people up with things that have other side effects and such and especially since I see children, I’m just dead set against prescribing any narcotics, and the world doesn’t understand we have so many options but you have to be able to spend time with the patient, and you have to pick the one or few medicines in combination that would be helpful without any dangerous risks. And, number one, it’s not worth my time. I don’t get paid for spending that time with the patient to figure all that out and then to fight with the insurance companies to give the best medicines when it’s not on their formulary — besides their formulary has changed frequently. And there’s so many insurance companies. So even if you were a genius and you could memorize all the formularies, they’re not going to be good next week.
Q: So what does that mean then for the children that you treat?
Niparko: They can’t get it anymore. With my epilepsy patients, it’s a big issue. It’s a lot of staff work to call the company, maybe they’ll put them on a special program to give them some free medication until they get it. But all of this is many phone calls, and much paperwork.
Q: Okay. So how are doctors like you coping, then, with these challenges?
Niparko: Five of the top world pediatric neurologists I’ve known in my life, they moved to Canada with the words “nobody’s gonna tell me who I can treat and how I have to treat them anymore.” And I have no doubt that their patients get better care than most kids I see around here.
Q: Right. Canada has a universal health care system, it’s publicly funded, and they have no insurance companies. What do you think of that system?
Niparko: It’s a better system. And we have a very good friend, an adult, who was diagnosed with prostate cancer and we were hoping he and his wife would move to where his friends are in L.A. and he can’t do that because all of his treatment is paid for in Canada. And, you know, long before I had all these years of experience, I was very much involved in baby development and premature babies and the complications that come with them and worked with kids with cerebral palsy a great deal, and the data is clear. If you are so unfortunate as to have a child with a serious developmental disability, chances are like 95% that parents are going to get divorced, and they will be financially destitute. That doesn’t happen in Canada.
Q: Why do you think that is?
Niparko: Because all of those things are paid for. As the examples I gave with MRIs, no, they may not get an MRI on their kid who has a headache because he doesn’t want to eat breakfast every day, but they get good care. And people say, Well, you have to wait six months to get surgery in Canada for something, blah, blah, blah. You know what? In this country, you have to wait six months or a year to get that MRI to diagnose what we know is wrong.
Thank you, Dr. Nancy Niparko.
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.
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