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Article Date: 03/25/2014
When insurers dictate medical
decisions
Have you ever had a
conversation that rattles around in your head for days? Maybe, it changed what
you thought you knew about the world. Perhaps the ideas or comments did
not make any sense. I had a discussion last week and it seemed that logic
stood on its head. The means was defined by the end, with no connection
to the beginning, or more exactly, the tail wagged the dog.
A skilled, respected physician and I were considering a
challenging case. The patient had an unusual problem and the therapy was
not obvious. We boiled down the therapeutic possibilities to three. The
first choice was a standard, the most used, best-studied treatment. The second
was a little radical with a small track record, but had been reviewed in two
publications. The third made theoretical sense, but had rarely, if ever,
been used to treat this disease and we could find no supporting research.
I was in favor of the
first treatment, the old standard. My colleague, who is naturally more
aggressive than I, suggested the last, the unproven, despite a lack of
data. I said, “But, there is no information, no research, no real proof
it could work.” To which he countered, “Maybe, but Medicare has approved
it and will pay for it.”
This is a staggering
piece of illogic. It suggests that medicine has evolved to the place that
doctors take their lead in making decisions from insurance companies, in this case
the federal government’s Center for Medicare & Medicaid Services (CMS).
Payment “approval” is the same thing as being medically
appropriate. This doctor did not say, “Well, I think the third choice is
right because it has a real chance to work with the least side effects, and, by
the way, I think CMS will pay for it.” Rather he said that primary reason
to choose a medically questionable treatment is that the government has deemed
it worthy, and therefore agreed to lay out precious dollars.
Ergo, the therapy is
right, because government and insurance actuaries can never be wrong and
guarantee of payment is the same as guarantee of clinical
benefit. Money = cure.
Apparently, this
doctor, like many others, has been beaten down so long by the insurance industry’s
pre-approval process, the constant need to beg an anonymous insurance
representative to give that warm and fuzzy “ok” to the doctor’s care, that
things have gotten flipped in his head. Now, at least some of the time,
we do not start with what the patient might need, but what the insurance
industry will support, and choose therapy from that restricted list.
Once upon a
time, the differential was a list of possible diagnoses,
which might explain the patient’s symptoms. Then doctors studied
the list to determine the actual disease and then, and only then,
the physician picked possible therapies. Now the differential is
a limited number of the treatments which have been chosen by the insurance
industry, possibly because they work and definitely because they are what the
corporation, stockholders and taxpayers can afford.
There is a warning
here for patients and doctors. If your doctor is recommending a
treatment, confirm the logic that lead to the diagnosis and understand the
data. Be careful that the therapy is not second best, because the indicated
treatment is not on the insurance company’s formulary.
More important,
doctors must endeavor to command the logical high ground, based on a system of
medical analysis as old as Hippocrates, which is designed to produce the best
care. Only when we have made the diagnosis and our recommendation of the
best treatment, should we play the insurance game. We must end at the
formulary, not begin, and we must be ready to fight for payment for what is medically
necessary and right. If we make our decisions based on solid science, we
will eventually prevail. Otherwise, we will find that we are simply dogs,
being wagged by our tails.
