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)

PROPOSITION 45 HEATS UP

Enter now Paul Y. Song, MD, into the Proposition 45 debate. Actually, he's been there all along, has already appeared in my edits, testified at the all day hearing on 45 before it was known as Proposition 45,  and is said by some to be a prospective candidate for insurance commissioner.

In his editorial entitled "Why Are CA Doctors Breaking Their Hippocratic Oath on Prop. 45," Song asserts that the doctors and nurses opposed to 45 are protecting the insurance industry. He says "it is unconscionable." His main point seems to be that there is no conflict with the "independent commission" whereas "Covered California is actually run by purely political appointees." THAT is no news to us -- we don't know of any commission where prospective appointees are required to pass achievement tests and demonstrate that they know anything other than how to make political contributions. Song points out that some of the Covered California persons "have a long cozy history with the private insurance industry." Song points out with some relish that "it is the private health insurance industry and their administrators, many of whom have never cared for a patient, who are denying care, while telling doctors what treatment and drugs they can provide."

Song says that Prop. 45 "would simply apply the same regulatory framework to health insurance which has proven so successful regulating auto, home, and medical malpractice insurance in California." He likens Prop. 45 to Prop. 103 vis-a-vis auto insurance rates.

The juicier parts of Song's editorial include his telling certain persons and groups to "stop spreading ... lies." Take a look at it, and Young's editorial, and Bussey's. In many ways Prop. 45 is more substantial as important legislation than Prop. 46.

Our point is that while Prop. 45 if it passes will have the bite of law, its eventual teeth will be in the rules and regulations that follow. The proponents will need to make sure that the rules and regs are composed by forces that want it to succeed. Are they ready and prepared for the job?

References

You can follow Paul Y. Song on Twitter at www.twitter.com/paulysong; Bussey's editorial is referenced in our previous post & appears in UAPD Pulse; Young's editorial is referenced in our two previous posts and on the website for the California Neurology Society 

Proposition 45: pro and con

Robyn G. Young, MD, president, California Neurology Society, presents her case for Prop. 45 in her editorial available on ca-neuro-society.org (it is also summarized in our previous blog in the end-of-article listing of references).

Now comes Stuart A. Bussey, MD, JD, president, Union of American Physicians and Dentists, who writes in the "The UAPD Pulse" why Prop. 45 does not deserve passage.

Bussey's piece makes these points:

1. Prop 45 would shift regulatory authority from an independent commission to one political figure who would then become a "pressure point" subject to special interests.

Comment: the independent commission is also subject to special interest pressure, but it's more difficult to get to an entire committee than one person. On the other hand, commissioners get their jobs by appointment, political appointment, not by scoring well on achievement tests.

2. Bussey points out that under the ACA administrative costs are limited to 20% -- anything over that "must revert back to patient services."

Comment: Trouble is that the insurance companies often try to sneak administrative costs into the "patient services" sector. Example are utilization reviews requested by insurance companies that seek to disguise them as "consultations."

3. If  Prop. 45 passes a likely revenge step the insurance companies will take will be to slash provider reimbursement. Agreed, that's what they'll do, not that they don't already do it. The independent commission has not roared its disapproval of provider abuse.

Comment: It's also likely that the insurance companies and MPNs (Medical  Provider Networks) will jettison hundreds of doctors as a way to reduce expenses (not that that hasn't already been done). That in turn will force the remaining doctors to see more patients faster (the short visit you get now will be made even shorter).

My opinion: if Proposition 45 passes, the next step will be the implementation of rules and regulations. Proponents should be ready to take that matter on from Day One. That means day-to-day readiness to participate in the regulatory process. Proponents feel they have a better chance at fair regulation with Proposition 45 than without it. Opponents are skeptical, and with good reason, e.g., the unions bent over backwards to get Brown elected Governor only to find out yesterday that he vetoed all three of their bills. Would a single insurance commissioner be different?

The latest re the ACA: a laboratory in San Jose has just  billed a doctor's office for laboratory work done for Medicare patients. The lab in question said that changes in the Affordable Care Act made in January of 2014 allows them to do so. We'll look into this matter and see what the current insurance commissioner wants to do --  it'll be a prelude to what he'd do were Proposition 45 to pass.

In our next blog, we're planning on a few parting shots re Prop. 46,

Question: When should lawyers be tested for drugs?

Answer: When they're awake.