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.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • doc99

    Hippocrates, not Hypocrites.

    • http://www.kevinmd.com kevinmd



  • Lisa

    As a patient, your colleague would scare the heck out of me.

  • http://clearhealthcosts.com/ Jeanne (clearhealthcosts)

    This is terrifying. It’s not up to an insurance company functionary to make this kind of decision. It’s up to you, my doc.

    I have a related question: can you estimate what percentage of your decisions are overturned or rejected by insurers? Or what percentage require further discussion or persuasion with insurers to acquire their approval?

    • Dr. Drake Ramoray

      That depends. Testosterone is a crap shoot and changes on a yearly basis. There is a learning curve.

      I know a primary care doc who refers everyone who fails Metformin and sulfonyurea therapy because he doesn’t want to do prior authorizations anymore.

      • Becky

        What is your comment? Try again worded differently.

  • buzzkillerjsmith

    Not just insurance companies. Your CorpMed employer too. Ka Ching!

    • Dr. Drake Ramoray

      Yes our hospitals say Levemir and Lantus are the same. Sure both long acting insulins. One can be dosed once daily in just about everyone and the other is only about 80% potent per unit and usually has to be dosed twice daily. But sure. They are the same.

    • SarahJ89

      I think Corp Med is the bigger problem in my area. They’ve bought up all the practices, using the cost of EMR as leverage, so there’s no place for a doctor to go. When you step into one of these practices you are no longer dealing with people, you are dealing with “policies.”

  • Jack London

    I don’t understand this article. How can a treatment that has “rarely, if ever, been used to treat this disease and we could find no supporting research” possibly be approved (the word used in the article) for this indication? And surely an off-label use needs some supporting research in the Medicare compendium for reimbursement. Or maybe it’s not a drug?

  • LeoHolmMD

    CMS is not an insurance company. It is government. Decisions are not based on science, any more than elections are based on science.

  • David Porter

    Were the other two therapies not covered? If they were, then the motive for choosing the 3rd couldn’t have only been because it was “covered”. Did it drive more revenues for the clinic than the others? When i read the article, it seemed like the doctor who suggested option 3 finds it surprising that CMS pays for the treatment despite the lack of approval, but ultimately, its the best option for the patient. That is why he said “medicare covers it” because otherwise it would be ruled out. So to me, this story tells points out an obvious fact of healthcare, that you do not suggest treatment that isn’t covered.

  • Eustice Seeney

    It’s almost like the insurance companies and managed care got a political booster upper, and they use those super powers to whittle physicians input down to mere suggestions rather than patient care.

    • buzzkillerjsmith

      Eustice is a super cool name. I wish my parents had named me Eustice.

      • Suzi Q 38

        I have never heard about that name.
        I think “Buzz” is just as good.

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