The Best Care Possible: You’re Worth It

August 25, 2010 -- I and many of my physician colleagues are tired, stressed, rushed and frustrated.  Federal healthcare reform may offer some distant relief to us, but today, it still seems miles away.

Daily, we must fight for our patients.  And often our adversaries are the very health insurance companies we need to closely work with.  My patients benefit when their care is seamless and integrated.   

Accountability and responsibility are also the hallmarks of the medical profession, but sometimes the provider and the insurer can seem at odds about the best and most effective pathway of care for the patient.  

This has spurred a movement to help insurers work better with physicians and health providers.

This movement is called the voluntary National Health Insurer Code of Conduct.  “Health insurers should provide access to necessary health care, protect the patient-physician relationship and accurately process medical claims, but too often they are an obstacle,” said the American Medical Association’s President Dr. J. James Rohack in May.   “The new Health Insurer Code of Conduct principles will help protect patients and physicians from questionable insurance practices by holding the health insurance industry accountable.”

The online petition is free to sign at www.insurepatientaccess.org.  Anyone -- doctors, patients, advocates, policymakers, friends and family -- can sign it.  It’s an important time for this movement because sometimes insurer practices, though often well meaning and aiming to save costs, can have the opposite effect.

One such often- used practice by health insurers is called “fail first.”  This means that before a health insurer will agree to cover a specific medication the patient must try and be unsuccessful at other, often less costly medication. The patient must fail on these medications. Unfortunately, fail first policies often require patients to endure monetary, physical and psychological distress. Fail first or switching patients to a cheaper generic often become more expensive in the long run.  The patient and physicians must have two, three or more additional appointments to chart the patient’s success. Then there is administrative paperwork, several conversations with the pharmacy and more time spent trying to help the patient get the most effective medication for his or her ailment.

Even when a physician thinks the treatment may not work, these policies can unnecessarily force patients to pay cost-sharing for the first steps of therapy and for additional medical visits; suffer physically because effective treatment is delayed; and tolerate side effects from inadequate medicines.

Many physician groups and medical organizations, such as the Center for Medicare and Medicaid Services and the Oregon Medical Association, have expressed strong language about the problems of policies that require patients to fail on non-indicated medicines before they can be covered/insured for the medicines that are FDA-approved for their condition or disease.

Ultimately, my colleagues and I work daily to ensure our patients are well taken care of. We believe that clinical judgment and patient choice, within the bounds of accepted medical practice, should take precedence over payer cost considerations in decisions about individual care. We strive to ensure that health professionals can retain the ability to address the variability of patient responsiveness and individualize care through access to multiple treatment options.  

We hold that patients who are stabilized on specific medications should not be switched to other drugs except when medically indicated. And we believe that both physicians and patients should be notified of pending changes to medication treatments and be provided an opportunity to appeal a change before it occurs.

Adds the AMA’s Dr. Rohack, “The health insurance industry has a crisis of credibility. With the enactment of federal health reform legislation, it’s time for insurers to re-commit to patients’ best interests and the fair business practices necessary to re-establish trust with the patient and physician communities.”
        
Dr. Morgan is a board-certified provider in internal medicine and pediatrics with Creekside Family Medicine in Medford, and a third generation Rogue Valley resident. See more about his practice at http://www.roguevalleyphysicians.com/cfm/providers.html