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Diluting profit's sway over tests is a must April 21, 2011 Fortunately for him, Michael Fields escaped being the latest poster boy for what happens when the profits of health insurance companies appear to trump access to necessary and immediate care. This essentially is the outcome so far of state Insurance Commissioner Karen Weldin Stewart's recent ruling that Blue Cross Blue Shield of Delaware broke the law by denying needed tests and linking exams for care to savings. Twice the Elkton man was denied nuclear tests before his doctors had to perform an emergency heart bypass surgery a year ago January. A study of the struggles of multiple patients and doctors, like Mr. Fields and his physicians, has prompted proposals for needed reforms from the insurance commissioner. Chief is the elimination of any influence of profits on decisions related to patient tests. Under Blue Cross Blue Shield's pre-authorization program, the insurer forced doctors to prove a test was needed before it would agree to pay. That's a perfectly reasonable requirement and appropriate business hedge against waste in an era when more and more imaging tests and costly equipment are located in private physicians' offices. However, tests are necessary to rule out the absence of a problem as much as they are useful for locating the source of ailments. A standard denial policy, tied in part to profits, defies the basics of an ethical standard of care. No doubt that's the reason that several months after Mr. Fields' emergency surgery, BCBSD removed the contract contingency that required MedSolutions Inc. to lose money if it did not reach a 20 percent savings on denying requests for medical tests. A second recommendation is to rely on the pre-authorization criteria of professional organizations, such as the American College of Cardiology in the case of Fields' heart problems. This should provide an objective source that is vested in high quality standards as their insurer. Mr. Fields' case, and Commissioner Stewart's ruling that BCBSD broke the law, have reverberated nationally. The U.S. Senate Committee on Commerce, Science and Transportation is requesting cardiac imaging denials over the last five years from BCBSD. In addition to considering possible fines, Commissioner Stewart is right not to exclude local insurers from this discussion of what is just another aspect of the reform of how health care is administered fairly, ethically and on time when it comes to the lives of patients. |
