CAN WE PLEASE SAY "NO" TO NO?!?

HEALTH INSURER DENIALS MUST BE CHALLENGED: PART 1

Rarely will something be written in this Blog upon which everyone can agree, but this is beyond dispute: I am not a rocket scientist. But it doesn’t take a rocket scientist to know that all too often a patient’s access to a particular treatment, surgery, diagnostic test, medication, medical device or care setting isn’t being determined by the education, training and experience of his or her treating physician or another qualified health care provider. With frequent tragic results and invariably delays of care that cost patients in so many ways those decisions regarding access to treatment options are driven by an insurance company – an entity whose business model is predicated on taking in as many premium dollars as possible, promising to pay claims when needed, and then working as hard as they can to make sure they pay out as few dollars in claims as they can get away with. THOSE are the ones making de facto treatment decisions regardless of their hollow pronouncement they are only making “coverage” determinations!

That’s a bunch of horse**** – [you all know what it is]!

Is my description of their business model an oversimplification? Of course it is. But does that make it wrong? If you weighed my little rant on a scale of 1-100 with 1 being a complete and utter fabrication with no basis in reality and 100 being the ultimate truth sought by philosophers and mystics, I dare say my oversimplification scores somewhere in the 65-80 range. There’s a lot more truth than fiction to the concept of payers denying care for purposes which, among others, line their pockets.

Of course this wouldn’t be a problem worth writing a single fragmented, compound sentence about if those payer decisions were well-reasoned, performed with only the patient’s best interests in the forefront of their corporate minds, and done in a manner consistent with current medical practice or even their own conduct. But it is a problem worth writing, ranting and raving about precisely because those decisions are all too often unreasonable, uncaring and devoid of any deference or respect due to a provider who is actually treatingthat patient. They are decisions which negatively impact patient care. They are decisions which stifle growth of technology which can help patients and their providers and they are decisions which lead patients to feel hopeless, helpless and desperate.

ISN’T IT HIGH TIME WE ALL JUST SAY “NO” TO INSURERS WHO SAY “NO”! ISN’T IT TIME WE ALL CHANNEL OUR INNER HOWARD BEALE FROM THE CLASSIC 1976 FILM “NETWORK” AND ADMIT THAT WE ARE “AS MAD AS HELL” AND WE ARE NOT GOING TO TAKE THIS ANYMORE?!?

For the moment let’s focus on the request for pre-authorization, that process required by a payer which compels their member to take hat in hand and plaintively ask “Mother May I?” to get coverage for the medically necessary treatment they’ve been prescribed. Insurers will sometimes respond and say it’s “not medically necessary.” Other times it’s considered “experimental, investigational or unproven.” Perhaps they’ll claim the service doesn’t need to be performed where the provider wants or maybe they’ll just obtusely claim it’s “not a covered benefit” knowing that really says nothing but also knowing many patients won’t know how even start to effectively challenge them. Payers hide behind myriad formulations of phraseology which boils down to “NO” – “Not Now” – “Not Ever!” “Now go away!”

I will admit they are sometimes justified; providers occasionally overreach / patients occasionally want something that might not be good for them. But that isn’t usually the case, even though payers are quick to point fingers at providers. It does not appear that any area of medicine is immune from the payer saying “NO”, whether one talks about innovative treatment modalities, so-called “disruptive” medical devices and related technology. Even treatments which were previously considered “standard” are seeing coverage eroding.

Recent history in spine surgery provides some timely and apt examples. Surgeons were surprised to see lumbar fusions for various indications such as degenerative joint disease, previously covered quite routinely, be suddenly denied in overwhelming numbers with payers doing their best Chicken Little imitation yelling that “the sky is falling” and claiming that more data was needed. That isn’t terribly different than the problems spine surgeons confront with (relatively) newer procedures such as artificial disc replacement in the cervical spine. Despite being called a very well-studied procedure with multiple level I prospective, randomized, multi-center and blinded studies, all of which have been published along with excellent follow-up…,” (Biggest Coverage Issues for Spine Surgeons in 2013: Q&A With Dr. William Taylor of UC San Diego) access to cervical disc replacement remains more difficult than it ought to be given its acceptance in the surgical community. And trust me, our office knows first-hand since we have fought over 350 denials of cervical ADR all over the U.S., nearly all of those denials based on the insurer contention that the procedure is “experimental, investigational or unproven.”

That is just a couple of examples. Anyone reading this can cite many more examples impacting patient access to care in all areas of medicine.

So the critical question is “How do patients and providers effectively challenge these unreasonable bars to treatment access?” Not letting them get away with it without a fight is easy to say, but the simple premise of being “as mad as Hell” and not taking it anymore isn’t executed as frequently or effectively as it could be. I know from experience that there are many reasons this payer-dominance is the existing reality. Patients become resigned to being under the control of the monolith insurer; well-intentioned practitioners are often unable to help because of limited time or resources; those who are willing often don’t know what to do.

Being Mad or saying No to No is nice as a start. But it is only that – a start. Offering specific suggestions, strategies and tools to help those who are truly interested in improving meaningful access to appropriate patient care, even if it is “new” or “innovative” or “disruptive technology” will be the focus of PART 2 of “Can’t We Just Say ‘NO’ To No?!?”

So stay tuned and feel free to submit your comments . . .

Especially if you really ARE a rocket scientist!

Be Well

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