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Nightlight for Our Souls

September 26, 2022

October 2022

Aaron Gerds, MD, Deputy Director for Clinical Research, Cleveland Clinic Taussig Cancer Institute Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityAaron Gerds, MD
Deputy Director for Clinical Research, Cleveland Clinic Taussig Cancer Institute Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University 

 

 

My four-year-old’s favorite band (right now) is They Might Be Giants, and his favorite song is “Birdhouse in Your Soul.”1 The song was written as a stream of consciousness from the perspective of a nightlight and contains several musical elements that are quite unconventional for a pop song. Sitting down to write this column, I had this little earworm of a song firmly dug in while I tried to excise this bee in my bonnet.

The song’s idea of a little bluebird-shaped nightlight as a luminescent friend is comforting, and the mentions of using simple communication and holding onto hope – a “birdhouse in your soul” – parallels what we do as hematologists. In today’s health care environment, we are often forced to struggle to get the best possible care for our patients, arguing against what the insurers deem allowable.

The opening verse of the song starts by assuring me that I have a friend, but then line by line it reverses to say that I actually don’t, and I can’t help but think that insurance companies are a bit like that. I had a call recently with a local hematologist to discuss a mutual patient. We waded slowly through the conversation, discussing the catch-22 in the patient’s treatment: she felt unwell, and the medications used to make her feel better could worsen her blood counts, which was counter to her primary treatment goal to be free from transfusions.

The other doctor and I were hesitant about what to suggest next. I can’t speak for person on the other end of the line, but I know exactly why I was hesitant. I was certain which treatment to recommend next – that was the easy part. But what I was about to suggest would subject my poor colleague to languish in the dark recesses of insurance authorization purgatory: the initial submission to use the treatment, followed by the counter request for more clinical information, which, once supplied, is followed by a denial and then an appeal, each submitted one after the other indefinitely. My colleague could really use a friendly nightlight to see her way through all that darkness.

It seems like most of the time, the option for a peer-to-peer conversation after the denial is not available. On the occasion it is an option, I relish the opportunity, as I have tricked myself into thinking it will always work. Certainly, if I get a compassionate human being on the other end of the line, we can get this done. Most often my argument is: This drug is indicated specifically for this disease by the U.S. Food and Drug Administration, whereas the alternative you are suggesting is not. Moreover, its use is supported by the National Comprehensive Cancer Network guidelines. No bells and whistles here, it’s a “simple message” that’s right to the point. These always-polite conversations end with the disclosure that my friend, of a whole 90 seconds now, does not work for my patient’s insurance company but rather is an independent third party hired by the insurance company to evaluate the claim and that the payor is not beholden to the decision they render. What? I’m pretty sure I’d lose it after the first time my post-​arbitration decision was promptly deposited in the circular file.

The insurance companies are actually giants, and I’m always in awe of how my fellow hematologists face them every day, like the proverbial David, picking up stones and slinging them in solidarity with our patients toward Goliath. Although there is some solace in the fact this fight is for a noble cause, it can be wearying. As with many aspects of being a part of the machinery of modern medicine, you almost need a “birdhouse in your soul” to protect the reason you’re doing all of this from the fight.

I often find comradery on social media, as many have taken to sharing stories of insurance authorization woes, especially folks like William Flanary, MD (@DGlaucomflecken), who has a deft hand at rendering the absurdity of it all into pithy TikTok videos. I don’t think we’re just a bunch of burnt-out docs complaining from the corners of our ash-laden offices (the piles of ashes being the result of my mind volcanically exploding repeatedly with every denial). Insurance denials are a real problem in medicine today.

A 2022 report from the Office of the Inspector General found that 13% of prior authorization denials in the Medicare Advantage program were for services that met Medicare fee-for-service coverage rules.2 It’s like walking up to a vending machine, putting a dollar in, and having the bag of chips satis­fyingly fall to the pick-up box fewer than nine out of every 10 times. Great for the waistline, but not a machine I would want to rely on.

I think we can agree that this needs to change. There is growing call for insurance reform based on a range of reasons, topped by the fact that delays in care harm patients. Publications are mounting in the peer-reviewed literature that point out a deadly pattern of denials and delayed care. Both traditional and medical news outlets have covered the story with increasing frequency, bringing this issue to the forefront of the public’s mind. Thankfully, legislative action is starting to take shape on both the state and national levels with bills like the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018).

The dawn of change will take time to come, but until then, hold onto the bright “birdhouse in your soul” and know that no matter how awful insurance authorizations get, we do all of this for the patient.

Aaron Gerds, MD
Editor-in-Chief

If you haven’t heard “Birdhouse in Your Soul” by They Might Be Giants, it’s a great song. But don’t take my word for it – listen to it yourself at youtu.be/vn_or9gEB6g or scan the QR code.

QR code for Birdhouse

 

References

  1. Linnell J, Flansburgh J. Birdhouse in Your Soul. Flood. Los Angeles, CA: Elektra Records; 1989.
  2. Office of the Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. April 2022. Accessed September 15, 2022. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf.

 

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