Top 5 Ways Your Insurance Influences Your Primary Care Doctor’s Care

Direct primary care patients

Health insurance is supposed to enable patients to more easily access healthcare. But that’s not always the way it works in practice. For many Americans, health insurance policies can run counter to your primary care doctor’s recommendations, creating an impasse that can impact your overall care. That’s not the case for direct primary care (DPC) patients, who do not use insurance for their primary physician visits.

And yet, it’s important to understand how insurance companies can interfere with treatments, diagnostics, and medications in a primary care setting. After all, the vast majority of American patients are locked into this system.

According to one survey, 87% of doctors reported that insurance companies interfere with their ability to provide individualized care. That DPC allows patients to step out of this system and engage in a more fully realized partnership with their physicians is one of its primary benefits. In this way, direct primary care more closely resembles a more idealized partnership between doctors and patients.

So, how do insurance companies interfere with your care? And what can you do about it?

1. Time with Your Physician is Strictly Controlled

Every patient’s needs will be different, even in a primary care setting. So the best system is one that provides each patient with the time they need, right?

Sounds great, but it’s not the way that most primary care physicians work in practice. You need individualized treatment but primary care physicians don’t have the time to devote to it. Why? Reimbursement from insurance companies isn’t enough. It used to be much better, but over time it hasn’t kept up with the costs of running a primary care office. Costs such as nursing and front office staff, billing and insurance, and others. As a result, primary care doctors need to see more patients in a day to make up the difference. That means less time per patient.

2. Treatment Choices are Limited and Second-Guessed

When you require treatment, your doctor will try to make the best possible choice for your health and your desired outcome. But in order for patients to receive that treatment, insurance companies must approve payment.

  • Often, insurance companies have established specific protocols for approving and denying treatments of varying types.
  • Sometimes, your specific circumstances might lie outside those protocols.
  • As a result, your insurance company might deny you coverage even when your doctor recommends a treatment for you.

There are also plenty of anecdotal stories of patients being denied important medications and treatments even when they seem to meet all the proper criteria!

There are ways to appeal the results of this process, but they’re often quite slow (and sometimes very arduous).

3. Your Physician Has Less Control Over Tests and Diagnostics

Modern medical tests and diagnostics can do amazing things: detect diseases, illustrate damage, and help keep you healthier longer. In theory, the tests and diagnostics ordered by your physician should be dictated by your symptoms, your health, and medical best practices. Unfortunately, insurance companies can sometimes meddle in this process, as well.

Many insurance companies have specific tests that you may or may not be allowed to undergo. These tests may be dictated by symptoms detailed on your medical records, the cost of the test, and more. (Rarely does a patient’s peace of mind enter into these equations.)

Likewise, insurance companies may sometimes require certain tests and diagnostics to make you eligible for certain treatments, even if your doctor can reasonably make a diagnosis without that test. For most patients, it’s not ideal to have the insurance companies making these decisions; they’d rather make these choices in cooperation with their primary care physician only.

4. Medications Prescribed

Again, in theory, your medications should be prescribed based on your needs. But insurance companies often have a variety of policies in place that make this process difficult for patients. For example, some medications may be denied by blanket policies if insurance companies do not consider them effective enough.

In other cases, some medications may be denied until others are first attempted. For example, your insurance company may want you to try a cheaper medication option before using the more expensive one–even when your doctor believes this may be a waste of time.

5. Delays in Care

In many cases, patients can’t begin treatments or schedule tests until insurance companies have approved (or denied) the procedure or medication in question. It’s something the insurance companies call “prior authorization.”

Unfortunately, this process can take days–sometimes longer. This means:
Patients are sometimes left in a state of limbo, where they aren’t sure what the next course of action will be.
Patients will sometimes get their hopes up for a procedure–only to be understandably crestfallen when the treatment is denied.
Patients spend more time dealing with symptoms than should be necessary.

The Benefits for DPC Patients

For direct primary care patients, insurance plays no part in the decisions made at the clinic. This means that your physician is free to recommend or prescribe the best possible medications or diagnostics as dictated by your symptoms and your health. Most members of direct primary care clinics get access to communication, routine appointments, and many lab tests–included in a monthly membership fee. Most importantly, DPC practices limit the number of patients they’ll have in their practice. This lets the DPC physician spend the time needed to get to know each patient, order tests, get medications approved by insurance, and numerous other details that all add up to high quality patient care.

In this way, direct primary care clinics can avoid much of the interference that comes from insurance companies–and help patients and their physicians work towards a healthier future.

Contact Progressive Health Primary Care today to learn more!