Denying care or denying payment?
Take a deep breath, and read
By Steve Lopez
Los Angeles Times
January 2, 2008
Preston doesn’t have cancer, but he was born with cystic fibrosis. And the cost of the medicine that keeps him breathing just shot up like a rocket, thanks to an insurance company decision I’m still trying to decipher.
… the cost of Pulmozyme… had been running them $30 a month. Suddenly it was $784.
If a cheaper generic were available, they’d gladly switch. But they said there is no substitute for Pulmozyme, an enzyme-based medication that controls mucus secretions.
Hoping for an explanation, and reconsideration, Preston’s parents filed a grievance. Blue Cross quickly rejected it.
“Pulmozyme is no longer a Formulary medication,” said the virtually incomprehensible letter, which gallingly suggested the increase was part of Blue Cross’ commitment to providing its customers “the best possible care and access to medications.”
When I asked Blue Cross for an explanation, I got this by e-mail:
“As with other health plans, the decision to add or remove a drug from the formulary is done through a review committee made up of medical experts. At Blue Cross, this group is the Pharmacy and Therapeutic committee. Pulmozyme is currently considered a specialty medication and is covered for our members, but at a higher member share of the cost than other medications. The goal of these ongoing reviews is to assure access to all necessary drugs while also keeping costs as affordable as possible for all of our members.”
And…
Individual and Family Health Care Plans for California
Blue Cross of California
We believe that the cost of our plans should be consistent with a member’s expected health care needs and risk factors. That’s why Blue Cross offers various levels of coverage.
And…
Moves from the Cigna playbook
By Giuseppe Del Priore
Los Angeles Times
January 3, 2008
Insurers always qualify their denial letters with a sentence to the effect that the doctors must provide whatever care is necessary and that the payment is a separate issue. Insurers never deny care — only the authorization for payment. To stall the actual delivery of care, insurers hold out an insincere promise to authorize payment if the doctor provides more information. This leads the doctor on indefinitely, while insurers never say absolutely “no” until the patient gives up or dies.
http://www.latimes.com/news/opinion/web/la-oew-delpriore3jan03,1,7350723.story
Comment:
By Don McCanne, MD
Preston’s family pays $1,200 per month for their high-deductible health plan. You would think that this premium would provide a level of coverage that Blue Cross states is “consistent with a member’s expected health care needs and risk factors.”
Blue Cross has been a leader in insurance plan innovations that slow the rate of premium increases (to a smaller multiple of the rate of inflation) in order to remain competitive in the health insurance market. Blue Cross suggests that they are balancing “assuring access” with “keeping costs as affordable as possible for all of our members.” But their scales are locked in at (barely) affordable premiums, which requires that they increase financial barriers to access. Changing the copayment for Pulmozyme from $30 to $784 is a good example. They continue to have “access” since Pulmozyme is still covered in another drug tier, and they continue to have “affordable” insurance premiums.
Giuseppe Del Priore’s op-ed makes a very important point. Insurers never deny health care. They only deny payment. They have a private contract with the patient, and they have another private contract with the health care provider. They do not use those contracts to prevent health care from being accessed; they use them to escape their obligation to pay for that care.
Or do they actually have that obligation? Not really. Their obligation is to succeed as a business entity by enforcing those contracts in a manner that accrues to their own financial benefit. That’s the way the marketplace works.
What if we had a universal public insurance program, owned and financed by the taxpayers? Would we have individual contracts with patients and providers that would be used to manipulate health care payments to accrue to the benefit of the administrators of the public program? Of course not.
Would we use our public program to deny access to health care? We might if that care were demonstrated to result in impaired health outcomes and impaired quality compared to care complying with more appropriate standards. But we would do that through a process that identifies beneficial practices and then realigns incentives.
Instead of a private system that uses innovations to deny payment for appropriate care, wouldn’t it be better to have a public system that is specifically designed to finance all reasonable health care services and products? Blue Cross doesn’t think so.