By | November 23, 2011
Do you have a job? Does your job provide medical insurance? Does your medical insurance also allow “flexible spending”?
Back in the day, you may have enjoyed being able to buy nutritional supplements and over-the-counter remedies with your “flex.” But guess what? The rules have been changed by the IRS and by your insurance corporation. While the new rules allow the 1% to retain more of your paycheck (which makes them happy), they are proving to be a hassle for doctors and patients.
The new rules do not allow you to purchase preventive items using flex dollars from your paycheck. They now must be prescribed by your doctor to treat a stated illness. These items include:
– nutritional supplements including fiber, vitamins, minerals;
– health club memberships, exercise equipment, or shoe orthotics;
– acne treatments and sunscreen;
– acid-reflux medications;
– a blood pressure monitor for home use, baby aspirin to prevent heart attacks, omega-3 fatty acid sources;
and others (such as cosmetic surgeries and electrolysis, which may seem like luxuries to some, and necessities that affect earning power, to others).
“No problem,” you think, “I’ll just have my doctor prescribe them.” And as a friendly doctor, I cheerfully go ahead and write you a prescription for some of these.
However, when you send it in, we’re both surprised to find it is declined. The insurance company now demands a letter from your doctor explaining what medical diagnosis is being treated with the requested items.
There are two problems with this situation.
The first is that there might not be a diagnosis. Since the rules specify that the purchase can not be for prevention, the diagnosis can not be “to prevent heart attacks and strokes,” “to prevent vitamin deficiency,” “to monitor blood pressure to prevent need for blood pressure medication,” or “to achieve and maintain healthy body weight, muscle mass, and strong bones.”
Instead, the diagnosis is going to have to be, “Abnormally high cholesterol” (unless your cholesterol has been normal), “Vitamin/mineral deficiency” (unless this has not been established), “High blood pressure” (unless your blood pressure has so far been normal), “[Medical] obesity,” or “Osteoporosis/osteopenia.”
This means that a.) you are going to have a potentially pre-existing condition entered into your permanent insurance record (if it isn’t already there), and/or b.) you are going to need extra testing to establish the diagnosis, and a comprehensive treatment plan to manage the condition.
This is what our system favors over simple prevention. This is what our system considers worth paying for.
That’s only half of the problem.
For the doctor, who very often is not aware of each insurance corporation’s special “flex” rules, it is very likely to mean 1/2-1 hour per patient (reviewing charts to show that the prescriptions are medically justified, writing prescriptions and explanatory letters, dealing with claims denials), for each time the patient wants to use their own money, from their flexible spending account. The typical family doctor has 2500-3000 patients. An employed person may want to use their flex plan once or twice every year. Unless the doctor or his helpers memorize the rules for each employer’s “flexible” insurance policy, it’s going to be a major hassle.
This all comes on top of the many hours spent by medical practices in dealing directly with insurance corporations, trying to get paid for the services they’ve already given (dollars the patient and their employer already handed over to the insurance corporation):
– Doctors, 3.4 hours per week, mostly obtaining prior authorizations;
– Nurses/medical assistants, 20.6 hours per physician per week (>13 hours per week obtaining prior authorizations);
– Medical clerical workers, 53.1 hours per physician per week (billing and obtaining prior authorizations);
– Practice administrators, 163.2 hours a year (managing contracts, settling disputes with insurances, etc.).
…Allow me to humbly add that in old-fashioned single-doctor micropractices like mine, most or all of those jobs (and hours) belong to one physician – on top of patient visits, phone calls, diagnostic reports, emails, prescription refill requests, and faxes.
Now you know why your doctor either sounded so snippy, or so tired, when you mentioned your “flexible” spending account! If you asked every doctor in the United States whether they’d rather be providing direct patient care, or arguing with insurance companies about whether they should pay for a bottle of baby aspirin, I bet I know what they would tell you.
I’m currently fighting this problem by understanding the “flex” rules, and figuring out how to explain them in plain language to patients, to try to avoid long drawn-out insurance battles – and I don’t get snippy, because I know how it is.
But really, recognizing the fundamental differences between the interests of the health-insurance-corporate 1%, and the interests of the ordinary-patient-who-wants-to-prevent-illness 99% – and acting on that understanding – is the only thing that will ultimately solve these problems.
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