My last action as a US medical doctor was further affirmation of my decision to leave this country and this system.

In two months my wife and I are moving to Canada for me to start a job working in primary care and long term care in Rossland, British Columbia. When someone asks me, “why the move?” my answer is always “Oh…a lot of reasons.” And I’ll say fully, we are consciously moving toward something, not away from something as Missoula has been really great for us. We are moving to an incredible place with a lovely town with amazing recreation and community. But one of the reasons to leave the US is that the healthcare system in this country is fundamentally broken and I cannot imagine a career fighting against capitalist interests in an innately and necessarily humanist profession.

Yesterday as I wrapped up with my last patients I got a message in my in-basket telling me a patient’s CT scan had been denied after she had already completed the scan. The insurance company offered me the option to complete a peer-to-peer as the only option for potentially having it approved. So I called the physician that they contract with/employ and who undoubtedly has financial interest in denial of claims. I explained the patient’s medical situation to her, that the patient had two chest xrays in the years prior for these symptoms but she explained that the patient needed a chest xray in the prior three months per insurance requirements. The doctor I spoke with affirmed that medically a CT scan could be justified but per their algorithm she could not approve it.

A peer-to-peer is a facade. It is two highly trained physicians discussing a patient’s case and the appropriateness of certain testing while being beholden to an arbitrary algorithm that does not account for nuance. I told her I was likely decreasing costs to their company and decreasing radiation to the patient and the doc agreed. But her hands were tied. A peer-to-peer gives us physicians the illusion of an intellectual conversation about appropriateness of medical care. But a well trained monkey could go through an algorithm and deny the claim. If the doc agreed it was medically indicated but still cannot approve it, then why waste 30 minutes of my time at the end of my day with the conversation? Just to appease me; to make me feel like I have some semblance of power.

They put up barriers at every turn. A peer-to-peer is just another one of those barriers. The insurance company is incentivized to deny, deny, deny as long as it doesn’t inevitably increase their costs in the long run. Even the act of getting a peer-to-peer is exhauting. You are put through a heinous phone tree and required to give about ten different 10+ digit identifying numbers several times. You speak with a non-medical person first. Then an RN. Then you are patched through to the doc. You have to provide identifiers, your name each step of the way as if that information cannot be passed on to the next person. They hope you will give up and the patient will foot the bill.

You may wonder why an insurance company doesn’t want to improve the health of its clients because that would likely decrease cost in the long run. The reality is, insurance companies want to keep you cheap, not healthy, until you turn 65. That is when almost everyone transitions to our socialized healthcare- Medicare. In addition, if you get sick enough, say need a transplant or go on disability, you will almost certainly transition to Medicare. Most chronic disease has the bulk of expensive consequences after the age of 65. This conservative misguided notion that “I don’t want to pay for other people” is delusional. You are paying for other people. And more expensive at that because we are prioritizing profits for shareholders over health of the population.

That CT scan was denied and the patient will foot the bill in full. The imaging company has certainly chosen a completely arbitrary price out of a hat that the insurance company typically pays a fraction of, which they call “negotiation”, but the patient will pay the full, exorbitant price. I am the face of this patient’s care so I will take the blame and frustration from the patient. We cannot continue on like this. This system is fundamentally, at its core, not viable.

I feel like a deserter in some ways. I think about the docs who go on mission trips to provide care to underserved communities globally. I think about the US as analogous to those communities in some ways, especially rural communities. Those docs probably feel the burden of under-resourced systems and resultant poor outcomes for patients. In the US we are heavily resourced but it’s completely unaffordable. However, in this system we are subject to vitriol from leadership, skepticism, and complete ungratefulness. The patient’s express distrust in our guidance while simultaneously pounding supplements pushed on social media by shill chiropractors and fringe docs.

I know the system in BC will have its flaws. But those flaws are not innate to the system and they are continually working to improve the system whereas in the US it seems the opposite is occurring. I’m eternally grateful to British Columbia and the community of Rossland for welcoming me and prioritizing their health and the health of their neighbors and community and am ecstatic for this change. My coworkers in Missoula have been absolutely wonderful and I’ll miss them dearly.