The Skeptical OB: Yes, the patient might die, but I'm not going to help unless I get paid.

Nonetheless, I was shaken up by the experience. She had only gotten the appropriate treatment because I had been willing to fight with the radiologist. In some ways, it had been a matter of luck. I wasn't busy with other things; the radiologist had aggravated me, and was determined to prevail. I was uncomfortably aware that had circumstances been different, I might have failed to force the issue, and the patient would probably have died.

Why did the radiologist refuse to do the scan? He was simply responding to the incentives and punishments put in place by the insurance company. They didn't want to pay for emergency scans so they made the requirements onerous. The insurance company was not wrong in assuming that patients without classic signs of DVT probably don’t have one, and they didn't want to pay for needless scans. The radiologist was not wrong in assuming that this patient didn't have a DVT and in assuming further that if he did the scan he would not be paid for it.

Almost everyone who has health insurance has fought with the insurer at some point because the insurance company has refused to pay. If you've done so know you just how frustrating that can be and how much time it takes. Doctors fight with insurance companies all the time, both to get approval for tests and procedures that patients need, and to get paid for visits, tests and procedures that have already occurred.

Most people don't realize that doctors are often forced to fight with each other. The perverse incentives and punishments of the existing insurance system mean doctors who are trying to treat a patient must argue with other doctors who fear they will not be paid for their work. Sometimes, rather than fight to the bitter end, a doctor will give up and a patient won't get a test or treatment that she needs. And sometimes, giving up could have fatal consequences.

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