4. Managed Care Organizations Practicing Medicine (Without a License)
Submitted by Dr. JG Kaplan on Sun, 2010-01-31 16:02
Just today in pediatrics, Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs. Last week Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain eardrop – not what the doctor ordered!
Mental Health Parity; Let the HMO's Be Damned!
To improve the insurance coverage of mental health care, employers and group health plans are ruled against discrimination, * i.e., providing less coverage for mental health conditions than physical ones.
Note: this rule was originally approved in 2008 and it will finally become law in July 2010. "The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt."
- However, under it, insurers can still second guess practitioners and challenge payment for lack of “medical necessity.” This is shameful on its face as any practitioner can attest—the patient is often in crisis, demanding treatment that is uncomfortable for the average doctor because of poly-pharmacy, black-box warnings on meds, and the unpredictable nature of mental illness itself.
- Then there's the insidious fear of litigation.
- How about Insurers' Hustle, Hurdles and Hubris? How arrogant of insurers when it comes to behavioral medicine--patients do not always know when they're not going to be able to cope and, by definition, they're unaware when on the 'slippery slope' of a breakdown. Compounding this is the stigma of mental illness that itself contributes to delays in diagnosis and treatment. Enter managed care with its promises of coverage, only to be followed by hurdles [see: "Battling for Health Coverage as Cancer Spreads"], denials and delays. Think you can legislate fair treatment? Think again--adding insult to injury, insurers "can still require prior approval of some services and can still charge consumers more for using doctors and hospitals that are not on a list of preferred providers."
- It is disgraceful that this coverage is job-related and it is outrageous that the immoral disparity was ever allowed. (But, it has not been that long since those with mental illness were incarcerated as the mainstay of treatment. [See Dorothea Dix's reform efforts in1844])
- The standards, guidelines and methods used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more rigorously. Discrimination is manifest by disparities such as: setting separate or higher co-payments or deductibles or applying stricter limits on the treatment of mental conditions, addiction disorders or physical illnesses.
Disparities are, unfortunately all too common in the insurance industry. "By sweeping away such restrictions, doctors said, the rules will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse."
Variation in Practice, Pay
Variation in Practice, Pay and Outcomes
Merrill Goozner writes in "McAllen, TX As Outlier? Why Not Houston?" [The LinkedIn Health Care Blog, Healthcare Market Business Development group, 2/19/10]: "that excessive health care costs arise at the level of the hospital-provider network. Thus, incentives that are designed to reduce costs should be targeted to specific networks, rather than regions or states." Notwithstanding, the continuing debate over regional variation in health care spending as expressed in "Looking Back, Moving Forward," the incidence of procedures, their costs and their benefit varies and that is a problem.
Some demand is driven by the payment and/or incentive system that is not aligned where doing more than is required at the point of contact has an impact on provider earnings or it improves patients' allegiance. A practitioner does not want the patient to go down the street and seek care elsewhere. There's also the insidious fear of litigation. Thus the healthcare system drives itself and it exploits certain behaviors.
As the progressive pundits like to remind us: it is hard to get someone to see something when their paycheck depends on their not seeing it. Toyota, Big Pharma, Denials of Care (or payment of appropriate, medically necessary care).
Does utilization review help? No, the same pressures on practice apply after you as a doc have been dinged by the HMO, especially when patients' anxiety remains. Peer review and self regulation within the industry is weak and reactive; it has largely failed to address issues that patients care about. Indeed, siding with the lawyers, torts may be the last vestige of accountability.
Post new comment