Who’s making the decisions about your health care?

Are insurance companies making more decisions about the health care you receive? While a decade or two ago utilization nurses working for insurance companies had some power to approve or reject certain treatments, the reach of insurers into the patient-physician relationship is lengthening.

In March, I reported that insurers were sending questionnaires to policyholders newly insured under Obamacare asking about their health conditions and medical needs. And some people were filling them out. But insurers are also going after policyholders like me who have been with them for a long time.

We are reaching a crossroads in this country in terms of physician autonomy, a point made by Dr. Luis Collar on KevinMD.com. In a cogent essay, Collar argued, “Despite the foul smog of competing interests that permeates this new delivery paradigm, one thing is clear — physicians are no longer calling the shots.” Collar wrote that for the medical profession’s collective integrity to be relevant there must be access and trust.

“We now equate ‘access’ with health insurance,” he said. “And doing so allows some to declare victory each time a new patient registers on Healthcare.gov. Quantifying access requires a broader perspective. Does five minutes with a physician constitute access?” If five minutes is not enough time to for a doctor to evaluate me and develop trust, does that mean I need a health coach paid by an insurance company to take over the job of my doctor?

In my case, I received a letter from Aetna, my Medicare supplement insurance carrier. The letter was an advertising pitch for getting “started on a healthier lifestyle” by taking advantage of help from a nurse who would act as my own personal health coach, part of a disease management program included in the benefit package my former employer apparently purchased.

The health coach was supposed to help me reach my best health by lowering my cholesterol, losing weight or helping me with serious conditions like diabetes. He or she could also review treatment plans and help me understand medications and discuss online resources. “Because of your health history, we think you might benefit from joining our program,” the letter read.

What health history were they talking about? I don’t have a weight problem. I don’t have high cholesterol. I don’t have diabetes. I exercise and know about preparing healthy foods, having taken oodles of nutrition courses in college. What in my medical records that Aetna scrutinized could have triggered such a letter? What did this coach want to discuss? Were my eye medications getting to be too costly for the company? Were they trying to switch me to a different eye med? That’s my biggest medical expense. Why would a coach know more about ophthalmology than the doctor I’ve been seeing for 20 years? Annoyed, I called the insurer.

The customer rep described Aetna’s coaching service as a health education program. And when I asked what in my file warranted the letter, she replied it was an “outreach letter to let you know about the program.” If there were anything I wanted to work on, the coach would be there for me.

I told her I was not interested. But the fact that she had my records in front of her and was prepared to pass them along to a coach whom I would know only on the phone got me thinking about whether my medical information was indeed as confidential as the outreach letter promised. It seemed like my record was an open book just waiting for the commerce of medicine to exploit.

It was clear the customer rep did not have an eager customer, but she still asked, “Can we call you?” if any concerns came up. After I said no, she said she had to ask one more thing. “On our calls we have to screen for depression,” she told me.

The rep said they are supposed to ask if callers are “down or depressed.” If I were, which I wasn’t, why would I tell her? “You’d be surprised how many people say ‘yes,'” she said. What if you say you are down you are down in the dumps because it’s been too cold for days on end? Does that mean Aetna’s coach will send you to a therapist? The rep did mention behavioral health as a service they provided.

My conversation with her illustrates Collar’s point. Who’s making the decisions about your health care?

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College, New York, NY. She blogs on the Prepared Patient blog.

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