Get The Gavel

A weekly SCOTUS explainer newsletter by columnist Kimberly Atkins Stohr.

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Without insurance coverage, this rehabilitation facility stay will cost tens of thousands of dollars, a bill she cannot afford to pay.

Peer-to-peer conversations, like the one we’re about to have, should be a chance for nuanced discussions and explanations of care. But they have evolved into a symbol of all that’s wrong with American medicine: financial pressure and resource scarcity crowding out the physician’s primary moral obligation to caregiving. They have become yet another hoop for physicians to jump through in order to provide and defend essential care.

My question is: As a doctor, how did you end up holding the hoop?

Jousting

I’ve done peer-to-peers for many patients with complex conditions. Recently, I performed a peer-to-peer for a nonverbal child with autism who was brought in for uncontrolled agitation; his family was searching for answers. Or there was the octogenarian with Alzheimer’s who came to the hospital with constipation and a bowel obstruction and ended up staying in the hospital for weeks. There was the non-English-speaking middle-aged man with advanced heart failure who had gained 10 pounds from fluid that had pooled like a swamp around his heart and lungs.

I hate the name “peer-to-peer,” a euphemism, as if it’s a chat over coffee and not the jousting it usually turns out to be. Yet these conversations are a standard part of the appeals process for denied health care services. The peer-to-peers I do are typically to dispute one of two rejections: denial of rehabilitation facility placement or denial of coverage for an inpatient stay.

The latter feels like a request to defend my work — I may be an inpatient doctor, but was it a full-fledged inpatient stay? Insurance companies will sometimes assert that it was something less — what is known as an “observation-level stay,” which is reimbursed at a lower rate.

In these instances, it feels like an argument over who needs the money more: the hospital or the insurance company? As community hospitals all over the country close and private insurers report billions in profits every year, it’s hard not to feel that we know the answer.

This is not to excuse hospitals, which put their own pressure on clinicians to perform peer-to-peers, due to their success in overturning insurance denials. When I’m at the hospital, I might be asked to do two or three in a week.

I get frustrated during these conversations. Hospital care doesn’t fit into tidy categories — and I struggle to explain that sometimes patients need intravenous fluids and oxygen until they don’t, and that even when they don’t need either of those things, they may still need to be hospitalized. Care is variable, human bodies are fickle, our physiology spontaneous, unpredictable, beautiful.

You used to know this too.

Because isn’t that what makes us peers? That we both went to medical school, had the same training, were taught to hold the same values?

*I wonder, which row did you sit in in the lecture hall? *

*Were you the one who packed a lunch each day and shared your home-baked muffins? *

*Were you the one who studied with me in the basement library until 2 a.m. each night? Who walked home late with me in the cold Michigan winters? *

Were you the one who darted ahead of the surgical residents, moving patient to patient, bucket of dressings in hand — impressing us all with how you somehow already knew the unspoken expectations of what to do?

*Were you there the night we passed our cardiorespiratory block and ate burgers at Casey’s? *

*Or when we danced shamelessly at Swing Night at the Blind Pig? *

I‘m having trouble recognizing you in any of those people.

Sometimes you’re retired, sometimes you’re a psychiatrist, sometimes you blow by formalities. Sometimes you’re in Minnesota, sometimes Philadelphia, sometimes Maine. Sometimes you’re not mean, you’re actually quite pleasant, and that is even more confusing. Sometimes you are mean, and I wonder what happened to you.

Did your empathy dwindle or was it never there? Did you burn out from the difficult work of being a clinician, your humanity subsumed by documentation, the fear of being sued, the pain of being too busy to watch your kids grow up? Or is being a physician adviser for an insurance company actually your way of helping patients, trying to advocate for them from the inside?

In theory, the peer-to-peer could provide a more collegial, transparent process for physicians to justify care after an insurance denial. It could be a way for doctors to advocate on behalf of their patients to someone who understands.

But in practice, these peer-to-peers are time away from the bedside, investigating my patients’ histories, calling their families. Time away from the work of medicine. Much like insurance denials in the outpatient setting, insurance denials in the inpatient setting utilize a considerable amount of resources and delay life-prolonging care. When you issue a denial, I feel betrayed.

I know our system is broken, and I know it’s not your fault. Doctors are angry and exhausted; patients are suffering from medical bankruptcy and feel helpless. The issue is not so much the peer-to-peer process itself as the fact that insurance companies are governing the care physicians deliver to their patients. When will we realize that we as doctors are peers — with one another, yes, but mostly with our patients? We too will be sick, be hospitalized, need care.

Do no harm

You hear me out about my patient. I describe how two other physicians have done peer-to-peers on her behalf and they’ve been denied. But I’m trying again because I can’t imagine her getting better without going to a rehabilitation facility.

Remember, “primum non nocere” — first do no harm.

At the end of the conversation you tell me you’ll do everything you can to push it through.

And you do. Her rehabilitation facility stay is approved. There is, it turns out, a glimmer of humanity in this process. A chance to do right. Thank you.