Monday, February 16, 2015

WHEN PATIENTS GET TOO EXPENSIVE TO TREAT


What do insurance companies do when medical expenses get too high for comfort?  How may insurance companies deal with expanding medical costs that lower shareholder return and that may cause reduced executive compensation?

Currently, rituxin is one of the newer agents recommended for the active phase of acute demyelinating disease, multiple sclerosis in particular, but also extending to a complicated condition known as "lupoid sclerosis." Robyn G. Young, MD, Alameda, formely, president of the California Neurology Society,  states that this treatment is a preferred regimen for active system disease. e.g., MS/demyelination accompanying systemic SLE.

However, reluctance on the part of payers to cover this regimen has been noticed by frustrated clinicians whose treatment decisions may be delayed or denied by insurers who may assert that a specific treatment regimen is "experimental" and therefore not eligible for coverage under the plan. If that happens, the patient is then denied insurance coverage and may have to pay for treatment out-of-pocket while the insurance company continues to bill for its alleged coverage, whatever of that remains once what the patient currently needs is denied. 

Insurance companies have other ways of controlling costs. One of these other ways is to limit access to physicians to cover the number of enrolled subscribers. That increases the length of time it'll take to see a physician, especially a specialist, which in turn reduces expenses for the insurance company, which in turn allows more favorable financial quarterly reports to be issued. Another technique is to drop physicians from the MPN (medical provider network) based purely on business reasons -- no allegation of poor medical practice need be made. This latter technique reduces short-term expenses, allows for more favorable financial reports on a quarterly basis, and runs little risk of collectively increased long-term expense because of delays of care. Keep in mind that in workers comp, for instance, Temporary Disability (TD) runs out in two years. 

Doctor Young stated that "our patients should not be the victims of either insurance or pharma greed ... the physician has been devalued while all the other entities with financial interests in rationing patient care have been elevated in control and influence."

That is why some medical organizations seem poised to fight simultaneously for their patients' rights as well as for the rights of member physicians lest the latter become indentured servants dependent either on the corporate mentality that rules Big Biz or the other corporate mentality that rules government. In this regard watch for a likely take-down on an aspect of Obamacare (Affordable Care Act). The case is King versus Burwell, Docket # 14-114, set for SCOTUS argument beginning on 4 March 2015. The case deals with an IRS ruling re availability of federal tax subsidies to persons who bought health insurance on exchanges run by the federal government -- we'll cover more on that in future columns.

In the meantime, Doctor Young's conclusion  that "it is time that we (physicians) took back our role as patient care advocates" should be shouted from physician rooftops everywhere.

References

"Regaining Control of Medical Practice," CLINICAL EEG,  c. 1995, V. 26, #1 (reprints available SSAE upon request to Dr. Weinmann, 2040 Forest Avenue, #4, San Jose, CA. 95128)

"Union head urges reform in health care," THE OAKLAND TRIBUNE,  4 November 1998 (White House press conference with then President Bill Clinton)



2 comments:

  1. Yes, ti is time that our physicians take back their role as patient care advocates. I just wonder why it took so long.
    Many injured workers have been waiting for several decades & now that same paradigm of evil & greed, all to deny, for insurance companies to save money & now on non injured workers who are considered real regular patients. Remember, that as injured workers not only were we injured but many of us did not & still do not get any real medical care. The denial of medical care started with workers compensation, the testing ground on how to deny to harm even more so & now injured or ill patients , that are not work related are suffering. Leaving millions without care. Where were our medical doctors as patient advocates? Millions of Injured Workers's receive the worst care or none. Either way, we've been left out because after all we're just injured or ill workers, Workers who are people & patients but who mean nothing to anyone because we're just "injured workers"!. No body to treat us for body injuries like our broken bones, nerves, ligaments muscles, no treatment for chemical or toxic mold exposures, lung or heart or gastro Illnesses No treatment for any mental related issues because we can't get medical care for our broken & ill bodies & for the way are treated like the insurance companies trash. We're just left with becoming sicker, in pain & die. Where are out physician medical care advocates? Physicians first do no harm, rail against the insurance system that makes life & death decisions & they aren't doctors, rail against any judge who dares to interpret doctors diagnosis's, judges who aren't doctors either, PLEASE advocate for all us who are patients , people who were injured on the job or who weren't & are sick or hurt! SO! many more don't suffer any more than they have to like the rest of us. Please do this as is written within your Hippocratic states, First do no harm.

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    1. Dina Padilla wonders why it took so long. The answer is that physicians don't like boardroom or executive confrontation which is precisely what is needed in this situation. That is the underlying reason why the Union of American Physicians and Dentists (UAPD) was formed in 1972. All the same, private practice physicians still prefer internecine conflict, private meetings with hospital and foundation executives, anything but collective bargaining. Nevertheless, many among us long ago spotted that the industrialization of medicine was the proper target, e.g., "Regaining control of medical practice," by this author, CLINICAL EEG, 1995, vol 26, # 1 (reprints available, SSAE send requests to Dr. Robert Weinmann at 2040 Forest Avenue, # 4, San Jose, CA. 95128).

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