Friday, February 17, 2012


In these columns ( we've previously pointed out how Utilization Review in California is twisted and turned to deny care to injured workers. We've also shown how the Affordable Care Act, aka Obamacare, contains a not-so-subtle rationing section known as the Independent Payment Advisory Board (IPAB) pursuant to Section 10320 of the ACA.

What's next on the Denial Menu is a method to deny care not only to injured workers and Medicare recipients, but to anyone, anywhere, anytime. The insurance companies are adopting plans based on science but far from scientific. Here's how such plans work and how they'll be used in compliance with the ACA.

Currently, insurance companies are allowed to warn subscribers about medications, adverse effects of medications, and how some medications may have ill effects if combined with certain other medications or substances. In the media limelight just now is how xanax and alcohol if taken together may prove fatal.

The program seems protective; however, practicing physicians know how insurance companies use this concept to push generic medications over trade-name products that treating physicians feel are superior or to deny a recommended treatment for another that costs less.

Practicing physicians have also observed that specific treatments with comparatively lower levels of success than others, sometimes the best bet for certain patients, may be denied because their overall success rate is less than a pre-designated level of success, say, 50%. But in some patients there may not be a better choice.

Delay and Denial Menus (DADMs)

This concept is being used to deny or delay diagnostic and treatment protocols, e.g, tests physicians use to decide upon diagnosis and regulate treatment. These Delay and Denial menus mean that insurance companies will not be obliged to pay for tests or treatments that don't measure up to internal business protocols that need not be explained or even made known to the public or to the companies' own subscribers. Here's how it'll work:

Insurance Company UltraNix may give its own grades to various diagnostic tests and treatments. Those tests and treatments graded "A" or "B" will get covered, e.g., maybe 100% for "A," maybe 75% for "B," maybe less for "C," and not at all for "D." The cut-off levels are decided by the insurance companies. Most likely to be effected will be cancer screening and other conditions where the last scientific word hasn't yet been written. One may reasonably ask why insurance companies shouldn't wait for the last scientific word. The answer is that science is slow, e.g., aspirin for protection from heart disease wasn't fully accepted until comparatively recently although medical and scientific data in support of this use was already in circulation for many years.

Because of the ACA such restrictions which amount to rationing may now enjoy the force of law despite President Obama's solemn promise in the autumn of 2009 that "I will ensure that no government bureaucrat gets between you and the care you need."

The restrictions shoved down subscribers' throats will not be subject to debate, disclosure, or revision -- these restrictions will be equivalent to "black box" recommendations just as those made by the Independent Payment Advisory Board (IPAB) even though President Obama recently promised in his State of the Union address that "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage or charge women differently."

One result of the ACA is to permit insurance companies to adopt measures to restrict benefits without actually cancelling policies. If insurance companies can deny claims based on internal protocols of their own and not cancel policies, they'll have the best of both worlds, i.e., your premiums and no obligation to pay out on claims for diagnostic tests, treatment protocols, or medicines.

One caveat: the insurance companies will be off-the-hook only with reference to paying for the diagnostic test or treatment that one's doctor may have prescribed. Patients who want to pay 100% for something that their insurance companies have refused to cover will still be able to do so.

If this concept sounds like a scam, that's because it is. What is sad is that it fits into the Affordable Care Act which allows for precisely those denials of care that President Obama said he would not tolerate.

Other References by Robert L. Weinmann, MD

San Jose Business Journal, week of August 3, 1987 ("... it is our business to know which contracts our doctors sign"

San Jose Mercury News, April 2, 1993, "Managed care: the dark side" ("... the plan's doctors ... agree that the diagnostic tests and treatment plans they may prescribe may be abbreviated or disallowed by the plan's cost controllers")

Congressional Record, May 27, 1993 (above, reprinted, with comment from Pete Stark, MOC, D-CA)

San Francisco Examiner, January 12, 1996, "Medical red-lining :'Economic credentials' for physicians"

Congressional Record, 9 September 1998 (above, reprinted, with comment from then MOC Tom Campbell, R-CA)

The Hill, Washington, DC, 9/16/09, "What Obama should've said about health reform"

POLITICO, 12/14/2010, Washington, DC, "How to ration care without using the 'R' word"

POLITICO, 01/18/2011, Washington, DC, "Section 10320 of the Affordable Care Act Should Be Repealed First"

POLITICO, 07/14/2011, Washington, DC, "GOP dilemma: How to oppose IPAB: The Independent Payment Advisory Board (IPAB) is bad for your health"

The Hill, Washington, DC, 12/02/12, "Patient advisory board will put cost before care"

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