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Insurance companies can be lousy advocates


A critique of the role of an insurance company, payer, exchange or entitlement program

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Jeffrey Gene Kaplan, MD, MS, a senior pediatrician and retired physician executive. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica. 


A critique of the role of an insurance company, payer, exchange or entitlement program

Insurance companies are trying to be a gateway, but unfortunately, this may also mean they are not playing fairly and not covering what the patient needs. For example:

·       We hear that Health Plan A refused to pay for a visit of a child with a probable goiter and strong family history of thyroid disease, a child who needed diagnostic lab tests. Why? They do not accept rule-outs. 


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·       Not long ago, Health Plan B levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium. Reason? This drop contains an antibiotic and a steroid, the components of which are not available generically.

Separating the mind from the body and spirit is antithetical to being holistic; it is piecework (where the incentive is to generate pieces)

Holistic thinking is important whenever we review, judge or reward performance in any and all aspects of healthcare. As an example, deficient mental functioning and/or mental illness must be taken into account as management considers the cost, quality and/or outcomes of care.

No discrimination allowed if it discourages appropriate care

To improve the insurance coverage of mental health, employers and group health plans must not provide less coverage for mental health conditions than physical ones. 

Nevertheless, insurers can still second guess practitioners and challenge payment for lack of “medical necessity.” This is shameful, especially if the patient is distracted or overwhelmed. But, be careful-such patients may be demanding treatment that is not indicated because of poly-pharmacy, black-box warnings on meds and the unpredictable nature of mental illness itself.

Patients do not always know when they're not going to be able to cope and, by definition, they're unaware when on the slippery slope of a breakdown. Compounding this is the stigma of mental illness that itself contributes to delays in diagnosis and treatment.


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Enter managed care with its promises of behavioral medicine coverage, only to be followed by hurdles-denials and delays. [See: "Battling for Health Coverage as Cancer SpreadsNY Times]. Think you can legislate fair treatment? Think again-adding insult to injury, insurers may require prior approval of pre-existing conditions and some services. Also, they can still charge consumers a lot for using out-of-network practitioners and facilities that are not on a very limited or restrictive preferred providers list.


Next: Insurance coverage is 'disgraceful'


It is disgraceful that insurance coverage is often job-related and it is outrageous that the immoral disparity was ever allowed. (But, it has not been that long since those with mental illness were incarcerated as the mainstay of treatment. [Ref. Dorothea Dix's reform efforts in 1844]).

The standards, guidelines and methods used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more rigorously. Discrimination is manifest by bureaucratic under-handedness or procedural inequalities such as: setting separate or higher co-payments or deductibles, or applying stricter limits on the treatment of mental conditions, addiction disorders or physical illnesses.


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According to Robert Pear in his Jan. 29, 2010 NY Times piece, "New Rules Promise Better Mental Health Coverage," such disparities are, unfortunately, all too common in the insurance industry. However, removing such restrictions, doctors say the improved rules of practice and coverage will make it easier for people to obtain care for an expanded range of conditions, including, but not limited to depression, eating disorders, alcohol and substance abuse, autism and schizophrenia.

When trying to improve outcomes and access while lowering costs, and with regard to pay-for-performance incentive programs and reward systems, the bio-psycho-social model is essential to use. Without it, care is likely to become fractionalized. [Reminds one of the parable of the elephant and the blind men.]

Do we have to make things more complicated than they already are?

Consider the complexity of the U.S. healthcare system, which is made worse by becoming over-specialized, or even compartmentalized. For example, memory problems, dementia and psycho-social disturbances are issues that are or have been siloed from the rest of health care. Indeed, Michael Craig Miller, MD, points out that the following (independent variables, as it were), are rarely mentioned in the medical history, assessment or, for that matter, thinking: transience, absentmindedness, blocking, misattribution, suggestibility, bias and persistence.

Medical management can ignore these contributing factors at their peril, leaving the whole process of paying for performance incomplete, misleading and otherwise problematic.


We invite comments, especially about comprehensive, responsible care and things that interfere with those objectives.


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