Economic Credentialing Reduces Access to Care

Much of the "health care debate" is not really about health or even health care. Rather, it's about financing the purchase of insurance products. And, having health insurance doesn't mean you have access to the care you need. Even for patients with “good” employer-sponsored insurance, the gap between "the best care" and "what is covered by my insurance" continues to grow. Smack dab in the middle of that gap sits insurance companies who use their business practices as a form of economic credentialing to ration and deny care.

Let’s be clear: Doctors detest any form of economic credentialing. Hospitals use it, instead of clinical skill or competence, to determine where and when a doctor might deliver certain services. And, insurance companies use it to rank doctors and ration care. Business practices such as cost profiles, network design, utilization review, and formulary tiering, force the hand of providers into making decisions that aren’t always in the patient’s best interest, but protects the insurance company’s bottom line.

Research shows the situation is getting worse. A recent survey entitled "Not What the Doctor Ordered" from the Doctor-Patient Rights Project (DPRP) found that insurance companies denied coverage for nearly a quarter of the Americans with chronic conditions or persistent illnesses. In a third of the cases, these patients, all of whom had insurance coverage, said their conditions worsened after being rejected. More than half (53%) of those denied coverage for a treatment of a chronic or persistent illness appealed the denial, but less than half (49%) of those appeals were ultimately successful.

Take my word for it. When I was receiving treatment for lymphoma, my doctors designed a plan to treat my aggressive and deadly form of cancer. Based upon scientific studies by leading cancer researchers, the plan promised the best chance for remission and cure. But, the insurance company would only cover the plan if I "failed first" on the standard regimen that had

been shown to be less effective for people with my disease. Here, "failing first" meant the difference between my life and death. I understand the fear of economic credentialing. No one wants to be punished for doing the right thing. Still, being adversely ranked on clinical performance measures relative to his or her peers, puts doctors in a difficult position, “Do I fight for the more expensive treatment I know my patient needs or go along with what the insurance company is willing to pay?”

Only after lengthy appeals and subsequent denials, I was able to obtain a personalized treatment plan. This therapy was precisely targeted, offered the fewest side effects and gave me the best odds for a cure. Because I knew how to navigate the system and fight insurance companies and paper shufflers who insert themselves between doctors and patients, I was able to get the care my doctor ordered. But even for someone with my expertise, it wasn't easy.

Some of my patients don’t fare so well. One of my patients developed chronic pain after multiple surgeries. Despite previous trials of medications, her insurance company required prior-authorization and imposed one-size-fits-all quantity limits on the amount of medication she could take. The delay in getting the proper prescription and dose of medication to her caused needless pain and suffering. Another patient, with no history of psychiatric illness, herniated a disc after a fall while hiking. He tried spinal injections, physical therapy, and medications but suffered permanent neurological impairment from delayed surgery because the insurer required a psychological evaluation prior to getting the operation both his surgeon and I felt he urgently needed.

Though there’s no scientific evidence to support insurance companies’ business practices, there is evidence those practices disproportionately impact our most vulnerable patients—people with chronic diseases, mental illness, and addiction. Often lacking “system-savviness” or well-organized advocacy networks, some of those patients end up sicker or suffering reduced quality of life. Researchers have found that formulary restrictions and other utilization review activities 

negatively correlate with health outcomes, can displace patients into other more expensive venues of care, and ultimately cost doctors and their staff as much as $31 billion per year in lost productivity and red tape.

Debating how to finance insurance for patients that doesn’t deliver the personalized care they need is nothing more than posturing. Patients don’t want a useless piece of paper and endless hoops to jump through to get the treatment their doctors order. They want the security of knowing that when they need access to the best treatment for their condition, their care doesn’t default to the lowest bidder.

Dr. David Russo is a physiatrist and interventional pain physician with Columbia Pain Management P.C. in Hood River specializing in regenerative medicine and cellular treatments for musculoskeletal conditions