Having resolutely avoided conventional healthcare providers for a few decades prior to last summer’s hypertensive crisis, I am a relative newbie to the vexation inherent in navigating the system. I couldn’t understand, for instance, why my urgent-care physician chose to send me to the ER for more tests rather than to the pharmacy for meds once she’d established that my blood pressure was out of control. Or, months later, why a shingles vaccination obtained at my clinic required an out-of-pocket payment while getting jabbed at my local drugstore would’ve been free.
Still, these were relatively painless detours on my reluctant healthcare journey. (Medicare, after some prodding, eventually delivered reimbursement for the shingles poke.) For many of my contemporaries, though, the routine pursuit of medical services can be surprisingly daunting, requiring a combination of time, energy, and patience few can sustain. Just ask Susanne Gilliam.
Earlier this year, Gilliam, 67, slipped on a patch of ice in her driveway, injuring her ankle and knee. She managed to wrangle an appointment later that day with an orthopedic surgeon who had treated her for previous knee issues, but he told her he didn’t work on ankles and sent her to another specialist who then referred her to a nearby hospital for an MRI and a new set of x-rays. But when Gilliam called to make an appointment, the referral had not yet arrived. It took multiple calls before she was able to schedule a time for the scans.
Scheduling physical therapy also proved more time-consuming than she’d expected. Because her therapists focused only on a single body part during each session, Gilliam had to schedule multiple visits each week. It was, she tells Judith Graham in KFF Health News, like working a part-time job.
“The burden of arranging everything I need — it’s huge,” she says. “It leaves you with such a sense of mental and physical exhaustion.”
“The burden of arranging everything I need — it’s huge. It leaves you with such a sense of mental and physical exhaustion.”
It’s a familiar refrain to the average member of the Medicare set, who spends the equivalent of three weeks each year in the grasp of our fragmented healthcare system — undergoing tests and treatment or simply consulting with their doctors — according to a recent report by Harvard Medical School researcher Ishani Ganguli, MD, and her team. More than one in 10 seniors, they found, spent at least 50 days each year receiving some sort of care within the system.
And those numbers don’t include the time spent on the phone or online scheduling appointments, traveling to and from those visits, standing in line at the pharmacy while waiting to pick up prescriptions, and haggling with their clinics or insurance companies over payment issues.
Older patients coping with heart disease often consult with three or more specialists, Ganguli, an associate professor of medicine, notes. And those suffering from a variety of other chronic conditions, such as diabetes and glaucoma, may regularly visit any number of additional providers.
“Some of this may be very beneficial and valuable for people, and some of it may be less essential,” she says. “We don’t talk enough about what we’re asking older adults to do and whether that’s realistic.”
The results of Ganguli’s research mirrors those of a 2020 Mayo Clinic study that found some 40 percent of patients suffering from chronic diseases considered their treatment burden “unsustainable.” But neither report focused on the time and energy required to respond to Medicare Advantage insurers that deny coverage based on an administrative maneuver known as “prior authorization.”
As Paula Span reports in the New York Times, insurers use this gambit to cut their costs, arguing that they must approve high-priced procedures, such as chemotherapy and inpatient surgeries, before they are performed. In 2021, these insurers denied some two million requests for coverage under the prior authorization policy.
“The rationale plans use is they want to prevent unnecessary, ill-advised, or wasteful care,” explains David Lipschutz, associate director of the Center for Medicare Advocacy. But, he adds, “Plans are making financial decisions rather than medical decisions.”
And patients, suddenly hit with massive out-of-pocket costs, typically aren’t aware of an appeal process — and the fact that most appeals are granted. A Kaiser Family Foundation (KFF) study last year reported that 35 percent of Medicare beneficiaries had no idea they could contest an insurer’s denial of coverage. As a result, only about 11 percent of denials were appealed — but 82 percent of those appeals were granted.
A Kaiser Family Foundation (KFF) study last year reported that 35 percent of Medicare beneficiaries had no idea they could contest an insurer’s denial of coverage. As a result, only about 11 percent of denials were appealed — but 82 percent of those appeals were granted.
Still, the process is daunting, requiring research, paperwork, and persistence from patients who likely are already overburdened by the routine demands of the healthcare system. It’s that reality, says Jeannie Fuglesten Biniek, PhD, KFF’s associate director of Medicare policy, that encourages the high volume of coverage denials. “Insurers may deny more aggressively because they know people don’t appeal.”
The Centers for Medicare and Medicaid Services has mandated stricter guidelines governing prior authorization that are scheduled to take effect in 2026, but enforcement remains a major question. And it’s unlikely that another layer of regulations will do much to relieve a patient’s general slog through the system.
At some point, all the paperwork, scheduling, and office visits — not to mention unfamiliar online patient portals — can so discourage seniors that they do what I did all those years ago: drop out of the system. This is particularly dangerous for poor and isolated older adults suffering from multiple diseases.
And it’s a problem few clinicians are equipped to solve, according to a 2022 study published in Mayo Clinic Proceedings. “We often have little sense of the complexity of our patients’ lives,” the authors noted, “and even less insight into how the treatments we provide (to reach goal-directed guidelines) fit within the web of our patients’ daily experiences.”
I’m luckier than most of my septuagenarian peers to have a primary care physician who also happens to be a neighbor, so she has a pretty good idea of what’s going on in this patient’s life — even if I make a point of avoiding such health-related topics when we run into each other on the sidewalk. She knows that I was tossed into the gaping maw of the Medical-Pharmaceutical Complex last summer quite against my will and that I’ll never be completely comfortable in a doctor’s office.
But I’ve figured out the patient portal and my pharmacy’s protocols, navigated without excessive trauma a CT cardiac calcium scan and a series of Mohs surgeries, and she knows I’ll come to see her if anything weird arises. Now if I can just figure out which vaccines to get at the clinic and which ones to schedule at the drugstore, I should get along just fine.
