Getting insurers out from between patients and doctors

July 06, 2010|By Gene M. Ransom III

As Maryland moves toward implementation of federal health care reform, it is critical to ensure that all Maryland patients have timely access to the care they deserve. But Maryland physicians have increasingly voiced their concerns about the significant and potentially dangerous ways in which health insurers are intruding on the doctor-patient relationship. Insurers' tactics are designed to deny patients access to care. Insurers create these barriers to access under the guise of cost control. In reality, this is not a controlling of costs but a shifting of costs within the system, and it actually increases the overall cost of health care to society.

The practices go by many names, but the result is the same. "Step therapy" is a practice through which insurers force patients to try and fail on up to five older, less effective medications before they will cover the course of treatment initially prescribed by the doctor. "Therapeutic substitution" is when an insurers or pharmacists switch a doctor-prescribed treatment for a non-chemically equivalent drug, often without doctor or patient knowledge. And "prior-" or "pre-approval" requirements force physicians to jump through administrative hoops, all while patients continue to go untreated.

A recent survey of Maryland doctors by MedChi, the Maryland State Medical Society, revealed that these health insurer practices are jeopardizing patient access to effective care in Maryland. The survey specifically found that 95 percent of Maryland physicians believed that certain health insurer protocols had a somewhat or very negative impact on the doctor's ability to effectively treat patients. In addition, 94 percent said that health insurance companies delay or deny prescription medications or diagnostic testing for patients. Nearly 70 percent of doctors indicated that hidden costs associated with meeting health insurer protocols have a significant to crippling impact on their practice, and nearly 77 percent said they have considered moving their practice to another state, retiring early, leaving the profession, or reestablishing their practices on a fee-for-service basis in order to avoid the administrative burden of health insurer requirements.

Health insurer protocols delay treatment for individual patients and cut into the time that a doctor has to spend with his or her patients — every hour that a doctor spends on administrative tasks is an hour not spent on patient care. To combat these egregious anti-patient health insurer protocols, MedChi has petitioned the Maryland Insurance Commissioner for a formal review of dangerous "cost containment" protocols, and we have urged the Health Care Reform Coordinating Council to identify ways to eliminate or streamline these practices as federal health care reform is implemented in Maryland. For our part, MedChi is investigating the development of a universal electronic process for streamlining and expediting health insurance carrier requirements. We are also working to develop patient protection standards that will more clearly define the boundaries around patients and their providers and reinstate providers as the primary decision-makers for patients' health needs.

Maryland doctors understand and support efforts to contain healthcare costs — when cheaper equivalents such as generic drugs are available and will work just as well, for example, our doctors prescribe them. However, insurance practices that require pre-approval, pre-certification and step therapy simply put barriers between patients and health care and will likely result in an increase of the untreated or undertreated. This will not only jeopardize patient health but will also likely increase costs in the long run, and the only parties who will come out ahead are health insurers.

Gene M. Ransom III is CEO of MedChi, the Maryland State Medical Society, which represents more than 22,000 licensed physicians in the state of Maryland. His e-mail is

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