Chicago Medical Malpractice Lawyer Blog

John Yates reports for the Chicago Tribune, “Michael Napientek of Clarendon Hills was in excruciating pain and needed back surgery. His wife has worked in the healthcare field for 30 years and thought she knew how to navigate the insurance bureaucracy.” Prior to the operation, his doctor obtained preauthorization for the surgery from his insurance company.

The operation was successful, and within a few weeks Mr. Napientek was feeling much better. However, in April, he and his wife “began receiving a series of letters from the insurance administrator with chilling news: Claims for the surgery has been denied, leaving them on the hook for the heart-stopping total of $148,000.” When they questioned the denial, they were told that preauthorization does not guarantee that the surgery will be covered. Mrs. Napientek appealed the decision three times, and was rejected every time. Each time, a different excuse was used ranging from accusing her husband of not exhausting “all conservative means of pain relief” to not providing “documentation to support the ‘appropriateness’ of the surgery.”

After many sleepless nights, several months of trying to figure out how to pay the enormous medical bill, and many phone calls to the insurance agency from Mrs. Napientek’s employer who funded the plan as well as from the “Problem Solver” of the Chicago Tribune to which Mrs. Napientek wrote to report this atrocity, the Napienteks recently received a letter saying the insurance company would pay for the surgery “based on additional information submitted and the opinion of an independent physician.” The Napienteks had already met their maximum out of pocket expenditure this year, so the insurance company will pay the entire $148,000.

As a Chicago medical malpractice lawyer I find it unacceptable that two working people with health insurance coverage could be driven into financial ruin because of health care costs, especially when the surgery was pre-approved. This story shows how vulnerable all Americans are to the whims and inordinate hassles of the insurance industry, and is yet another example that supports reform.

Chicago Sun Times writer Monifa Thomas reports that Blacks and Hispanics who receive treatment for head injuries and other trauma are more likely to die than whites with similar injuries. New research also showed that regardless of race, uninsured trauma victims died more often than those who were insured.

The study, published in the Archives of Surgery, offers the latest evidence of how race and insurance status affect patient outcomes -- whether the condition in question is cancer, heart disease, car accident injury or gunshot wounds. Data collected from more than 376,000 patients at 700 hospitals showed that trauma victims who were white and had health insurance fared better than Blacks, Hispanics and the uninsured, even when the severity of the injury was the same.

According to researchers, lack of insurance was the biggest predictor of poor outcomes—and since minorities were more likely than whites to be uninsured they were more likely not to survive traumatic injury. But the data also showed that Hispanics with insurance were still 51 percent more likely to die after being treated for a trauma wound than whites who had insurance. African Americans with insurance were 20 percent more likely to die compared to insured whites.

There are some variables that could cause this disparity such as uninsured patients having preexisting conditions that hurt their survival chances or the fact that minorities are more likely to be treated at under-resourced facilities. But in theory, trauma centers, are supposed to treat all their patients the same, regardless of whether they are insured and regardless of their race--any practice other that would be a violation of federal law. If anything, this study brings to light how universal health care coverage could help alleviate the disparity between the care “haves” and the 47-million uninsured “have-nots” receive.

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Does linking Chicago doctors’ pay to performance mean better healthcare? That’s essentially the question posed by Dr. Sandeep Juahar this week in the New York Times. Apparently, employers and insurers, including Medicare, have started about 100 initiatives across the country that reward health care providers by paying for performance-- called P4P for short--with the general intent to reward doctors for providing better care.

For example, doctors are now being encouraged to voluntarily report to Medicare on 16 quality indicators, including prescribing aspirin and beta blocker drugs to patients who have suffered heart attacks and strict cholesterol, for prescribing ACE inhibitor drugs to patients with congestive heart failure and administering antibiotics to pneumonia patients in a timely manner. The doctors and hospitals who perform well receive cash bonuses.

On the surface, it seems like a good idea to reward doctors and hospitals for quality, not just quantity. But there may be unintentended consequence to P4P. For example, Medicare requires that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The problem is that doctors often cannot diagnose pneumonia that quickly. It takes blood tests and chest X-rays to detect pneumonia, but the Medicare standard pressures doctors to treat an illness that they don’t have the solid test results to confirm. So as a result of the guidelines, ER patients are taking more antibiotics despite the risk of dangers of antibiotic-resistant bacteria and antibiotic-associated infections, like colitis.

Juahar claims that with P4P giving out bonuses, many doctors have expressed concern that they feel pressured to prescribe “mandated” drugs, even to elderly patients who may not benefit, and to cherry-pick patients who can comply with pay-for-performance measures. Juahar claims that whenever you try to legislate professional behavior, there are bound to be unintended consequences. And at this point, it is not clear that pay for performance will actually result in better care, because it may end up only benefiting physicians who already meet the guidelines.

The Chicago Medical Malpractice attorneys at Hurley McKenna & Mertz, P.C. think that Doctors and hospitals should never have to take a financial hit for trying provide innovative healthcare that the guidelines have not had the opportunity to address. If they can collect bonuses by maintaining the status quo, what is the incentive to improve?

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