Insurance companies playing doctor? You don't say!

TREATMENT QUESTIONS
Insurers playing doctor, docs say
June 2, 2008
By Suzanne Hoholik
THE COLUMBUS DISPATCH

When you are sick or injured, you want your doctor to concentrate on making you better and your health-insurance company to pay for the bulk of the care he or she prescribes.

But physicians say they are spending more time trying to convince insurers that a treatment plan is necessary.

"The insurance companies call all the shots," said Dr. Neal Nesbitt, a general surgeon in Athens. "They decide what they want to pay and what they don't want to pay."

So patients either abide by the health plan's decision and forgo a treatment or spend more of their own money to follow their doctor's advice.

Health-insurance companies say they are trying to control spiraling costs, and questioning doctors' orders is one way to do it. Physicians should have to explain, for example, why they write prescriptions above a recommended dose or order expensive MRIs before prescribing physical therapy.

The number of CT scans performed nationwide increased 13 percent from 2000 to 2005, according to the Center for Studying Health System Change.

"We know there's an overuse of care that costs, but it's a fine line," said Alwyn Cassil, spokeswoman for the center. "You have to balance that with individual doctors feeling that their autonomy is being questioned."

Some insurance companies demand that doctors point to evidence, such as a published medical study, to support a change in decision.

"If you want to go over the limits, you have to call us and tell us why," said Debora Spano, a spokeswoman for United Healthcare.

One doctor can see several hundred patients and contract with 30 to 40 insurance companies. That means that a doctor can spend several hours on the phone each week arguing about the care he or she prescribes.

"There's really no uniformity or even a way for the doctors to know what might be covered under your plan versus someone else's plan," said Tim Maglione, spokesman for the Ohio State Medical Association.

For example, this month, United started to strictly follow dosage and quantity recommendations approved by the U.S. Food and Drug Administration for medications to treat schizophrenia and bipolar diseases.

Spano said this is to avoid bad reactions sometimes associated with higher doses.

But physicians say recommendations by drugmakers and the FDA aren't intended to be hard and fast rules, especially in terms of treating mental illness.

"When insurance companies tell a patient they will not permit him or her the quantity of medicines prescribed by their doctor, they're approaching the practice of medicine," said Dr. Alan Levy, a Columbus psychiatrist.

Drugs to treat schizophrenia and bipolar diseases, for example, are expensive, so when a health plan stops paying for a higher dose, the patient has to pay more or go without the pills.

"There's just study after study that shows this is not the way to save money," said Laura Moskow Sigal, executive director of the Mental Health Association of Franklin County.

Not all health plans have this policy.

Cigna Healthcare, for example, is notified when a prescription that exceeds a recommended dose is filled. Then the company calls the doctor.

"We're leaving it to the physician and other health-care professionals to make that call," said Yi Zheng, assistant vice president of clinical programs at Cigna.

He said this happens less than 3 percent of the time.

But for every company that defers to doctors, there seems to be another that denies coverage. Working through these different policies is a growing frustration among physicians.

"I hardly appeal anymore because it just goes nowhere," Nesbitt said. "It de-professionalizes the entire profession, and it puts all our patients in a medical straitjacket."