Is Medicine an Art or a Science?

My oldest daughter was born with several health issues; a cleft palate, low muscle tone, windswept feet, and jaundice.  As new parents, my husband and I were beside ourselves on how to care for our new baby.  We were lucky to find a pediatrician who calmed our fears while offering great care to our daughter.  A piece of advice that he gave me is that he trusts a mother’s intuition regarding her children; in other words, if a mother thinks something is wrong with her child, she is usually right.  I have used that philosophy for the past 23 years in raising our daughter and two other children and it has always proven accurate. 

Health Day has recently reported on a study regarding intuition:

“Doctor’s intuition that something is seriously wrong may have more diagnostic value than many symptoms and signs, the report suggested.  Parental concern that a child's illness was differentthan normal was another strong influence on gut feeling, the study authorsnoted in a journal news release.  A gutfeeling should prompt doctors to conduct a full and careful examination, seekadvice from a more experienced doctor, and advise parents what to do if theirchild's condition worsens, the researchers concluded.”

Doctor’s use experience as well as education to treat patients.  Medicine has always been more of an art than a science.  Today, however, there is a push to make medicine a science, removing all subjective processes from t he experience.  It is a push under the title of “Medical Necessity”.  Medical Necessity has been pushed by the government for the past few years to have doctors use tests and past performances to treat a person.  Now private insurers are jumping on the bandwagon.  United Healthcare recently released a notice that it would implement Medical Necessity in inpatient care beginning Oct. 1:

“As a reminder, Medical Necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. The Medical Necessity process is based upon a foundation of evidence-based medicine and:

·  Provides an opportunity to address covered services at the individual level to support enhanced access to quality care for the member.

·  Utilizes generally accepted standards of good medical practice in the medical community.

·  Offers timely communication between health plans, members and providers to allow for prospective, concurrent and retrospective review as well as appeal rights for adverse determinations.

This foundation supports United Healthcare’s overall goals for providing enhanced access to quality care by raising performance standards and reducing variation in medical practice, and health care affordability by implementing a process that promotes efficient delivery of high-quality care in a cost-effective manner.”

What is important to note in this missive is the sentence: “The Medical Necessity process is based upon a foundation of evidence-based medicine.”  Evidence-based medicine is defined as "treatment based on tests, labs and best medical practices for the medical condition."  The problem is that diagnosing based on tests and labs is easy for the obvious conditions, such as a broken arm or an ulcer, but as a doctor once remarked to me “you cannot see pain on an x-ray”.  In other words, not all medical problems can be determined from a test or lab.  There are many anecdotal examples of doctor’s misdiagnosing or missing a serious problem, even with tests.  This was brought to attention recently in an article in the Daily Mail about a woman who died from undiagnosed cervical cancer.

If physicians will now only be paid for evidence based medicine, then many diagnoses that are being paid for today - such as chronic fatigue syndrome, depression, or low muscle tone, which cannot be determined by a test but instead by direct observation and physician expertise - will no longer be viable diagnoses.  At the end of the day, as much science as there is in medicine today, it is an art and art cannot be measured.

Medical Necessity vs IVF

In our backyard, we have a woodpile from which we feed our fireplace during those notoriously harsh Ohio winters. This summer, a clan of bees decided to make their home therein, a fact of which I became acutely aware when I went to retrieve some wood for our outdoor firepit. Apparently, bees do not like to have their natural habitat disturbed, and I was treated to a stinging demonstration of their displeasure.

I mention this anecdote because, while commenting on an excellent post over at the Health Business Blog, I have managed to set off a swarm of indignant women: another commenter, Susan opined that In Vitro Fertilization (IVF) should be a covered medical expense, and others soon joined the chorus.

I demurred, thus setting off the swarm.

Because I am an insurance critter, I tend to see these things through the simple lens of “risk.” Risk is defined as “the chance or possibility of loss,”and insurance is all about managing risk. I am of the opinion that lifestyle choices such as IVF do not fall under the aegis of risk management. Now, in my own defense, being of the Y chromosome crowd, I am perhaps less sensitive to this issue than XX’ers [ed: is that even a word?]. Nevertheless, I stand by my analysis.

It may be helpful to define what constitutes “medical necessity,” at least insofar as IVF, or Viagra, or baldness cures are concerned. For example, I readily admit that I am close to actually mainlining Rogaine these days, but it does not seem to me reasonable that my insurance policy should reimburse me for that. After all, no one has ever died or became acutely ill by becoming bald. Likewise, search as I have, I can find no evidence that anyone ever became seriously ill, let alone died, because they were unable to easily conceive.

So, what then constitutes medical necessity? Well, according to the standard industry definition, “medical necessity refers to treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.” Thus, we see that IVF fails to meet the threshold of “medical necessity,” ergo it should not be covered by insurance.

But Prof, you may ask, what about all those other “lifestyle” treatments and medications that insurance covers, like Viagra, or “the pill,” or even hair transplants?

There are actually two answers here. The first is that some med’s and procedures are covered because of competitive pressure (Viagra), or collective bargaining (“the pill”). And some, such as hair transplants, are covered by brute force of the gummint. That is, coverage for such treatments has been mandated by various state and/or federal legislatures, and thus became part of the contract, as well as 17% (or more) of the cost of your medical insurance.

So, when an IVF advocate demands coverage for that regimen, she is saying that she believes that you and I should help pay for her to conceive a baby (or babies). There are only two ways that this is going to happen:

An insurance carrier (or some insurance carriers) will determine that this is an under served market, and offer it as an optional benefit. Of course, this presupposes that there is a huge groundswell of folks who want and/or need IVF treatments, and are willing to pay extra for that coverage, and that other insureds don’t mind the premium increase to cover them.

More likely, though, she means that she wants IVF to be a mandated benefit, and thus advocates that the government should force you and me to help pay for her to conceive a baby (or babies). I may well have had my own plans for that money, but will now have to re-budget because those dollars have been forcibly taken from me, and given to her. Somehow, that doesn’t seem quite fair.

Now, I suspect that none (or very few) of those who advocate coverage for IVF really want to take my money from me, nor would they explicitly agitate for that. But that is precisely what they are advocating, whether or not they realize it. Their argument seems to be that they somehow deserve to have children, and I am standing in their way because I am reluctant to help them pay for that wonderful privilege. By this logic, of course, the costs of adoption should then be a covered medical expense as well. Again, I must pull out my lens, squint carefully through it, and declare that neither of these rises to the level of medical necessity, and wishing that it were so isn’t going to change that diagnosis.

It will be interesting to see how those who favor IVF coverage will address this post.

Medical Necessity: Here we go again

If you want to understand why your rates keep going up, you can lay a big chunk of the blame on items like this (in email from Medical Mutual this morning):

"To be compliant with the non-discrimination rule outlined in the Affordable Care Act (section 1557), we will remove broad exclusions for gender transition treatment"

Let's dial back a bit, and talk about why this is so stupid. In the earliest days of this blog, we participated in a discussion with other bloggers about medical necessity and In Vitro Fertilization (IVF). We averred that:

"[A]ccording to the standard industry definition, “medical necessity refers to treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.” Thus, we see that IVF fails to meet the threshold of “medical necessity,” ergo it should not be covered by insurance."

That is, no one has ever died because they couldn't/didn't get pregnant. Likewise, there is no evidence that anyone has ever died because they didn't get their personal bits chopped and/or replaced (excluding obviously medical issues like cervical or breast cancer and the like). There is, however, ample evidence that these folks are at much higher risk for attempting suicide (which would then require medical treatment in the most expensive part of the hospital).

So when insurers are forced to pay for non-medically necessary procedures, that cost is going to be passed along in the form of higher insurance premiums. Now, am I blaming Medical Mutual for this change? Of course not, they're simply following directives sent down from Our Betters in DC©.

What choice do they (or any other carrier) have?

It's not rocket surgery, after all.

Medical Necessity vs (Stupid) Mandates

A dear friend sent me the link to this story:

"Regence BlueShield has been ordered to pay $148,000 to nearly a thousand women who were wrongly denied coverage of prescription birth control ... Regence had denied coverage of IUDs, or intra-uterine devices"

As a tried and true liberal, she was pleased that the carrier was "punished" for failing to provide coverage for these devices. The problem, of course, is that they fail to meet the very basic test of "medical necessity," and should not be covered in the first place. However, liberals like their freedom to indulge consequence-free, and were able to convince the state of Washington to make other people pay for them.

There are virtually no circumstances under which these units are used other than to prevent pregnancy. As we know, pregnancy itself is not a disease or injury. Of course, common sense has no place in these kinds of discussions: like IVF, Viagra and Rogaine, we want what we want when we want it. And just like those three, birth control per se does not meet the definition of medical necessity.

My friend then claimed that Viagra is a covered expense; I replied that this is true only under collective-bargaining agreements and self-funded plans. In other words, you have to specifically add it to get around the fact that there is no medical necessity associated with it.

To put this in its proper perspective, consider this: would you expect your auto insurance to pay for your broken air conditioning? Yes, it's inconvenient and uncomfortable, but one can always roll down the window. And it doesn't necessarily affect your gas mileage (in fact, leaving it off may improve your mpg). Regardless, it's not an essential component, and I can guarantee that you wouldn't like your premium if coverage was required.

Obviously, the carrier had an obligation to abide by "the rules," so I lay the blame for this at the feet of ignorant state legislators who passed the bill mandating this coverage. Their rationale, by the way, was that "failure of insurers to cover prescription contraceptives had amounted to gender discrimination, and that women of childbearing years were spending nearly 70 percent more than men for health-care costs."

Sure.

On Health Care Reform and Abortion

There is perhaps no more divisive nor explosive issue than abortion, and we take no official stand on the morality of it. But as we've written over the years, we are most definitely proponents and advocates of the concept of "medical necessity" and the role it plays in risk management, of which insurance is a useful tool.

Contrary to previous reports, it now appears that the current proposal would, indeed, mandate coverage for abortion. Currently, the Hyde Amendment prohibits the use of public funds for that procedure; one supposes that there'll have to be some kind of legislative sleight-of-hand to get around that.

There's a more important consideration, though, which is whether there is ever a circumstance where abortion is "medically necessary." There are likely some obscure, rare circumstances (besides "the mental health of the mother") where this may be the case, but it's unlikely to be applicable in many cases. Absent medical necessity, it appears that this provision represents another mandated benefit, the cost of which will be borne by people who not only don't need it, but whose faith and convictions prohibit it.

The medical issue most relied upon by those who favor abortion is the mental health of the mother. We'll leave it to others far more qualified to speak to the validity of that argument, but we can look to how mental health benefits are currently covered for guidance in that area. The Mental Health Parity Act requires that certain benefit levels be covered under certain forms of insurance. For the most part, these apply only to group plans; individual plans, regulated at the state level, have much lower policy limits for Mental and Nervous. And, even on the group level, certain restrictions may be applied (for example, only in-network providers may be used, or the number of visits may be limited). So there's precedence for restricting benefits attributable to mental health.

Perhaps the larger issue will be the Law of Unintended Consequences. For example, those providers who choose to accept Medicare or Medicaid patients must adhere to the dictates of those programs. They can't balance bill, and they have to provide the services required by the programs. If a Public Plan becomes reality, those providers will have to decide whether or not to accept patients covered under that plan, which would apparently now include abortions. I can think of more than a few providers that might have significant issues with that.

And there's this: in its current form, it appears that while the Public Plan would cover abortions, it couldn't use federal funds, only whatever it takes in in premiums. I can think of a few more Unintended Consequences to that, as well: there may well be those who might choose the PP, but for the fact that they are opponents of abortion, and don't want to see their own dollars going directly to pay for someone else's abortion. And what about "partial birth abortion?" There is no medical justification for this procedure, and one wonders how (or if) it will be covered.

The other issue is one of utilization: when something's covered, it generally gets used. For example, the reason that maternity coverage on individual plans is so expensive (when it's available at all) is because carriers know that it has a 100% utilization rate. That is, everyone who buys that coverage ends up using it. By contrast, not everyone ends up with a broken wrist or cancer. So will abortion coverage (a related and elective procedure) also result in over-utilization, and hence significant rate increases?

Time will no doubt tell.

We Get Mail!

We do, indeed, get quite a bit of email here at IB; some's good, some's interesting, some's spam (or worse). We endeavor to answer all our (legit) email promptly, especially when it comes to claims or coverage issues.

Recently, we received this from one of our readers:

"I have always had a horrible fear of the dentist. I am 46 years old and though it is a tad better, I still tolerate long appointments better with nitrous. At my age, evidently I am all into the "crown stage"...either that or I am paying up someone's college fund.

My insurance will not pay one dime towards nitrous. Why? Medically unnecessary? They'll pay for one or two little pills if the dentist chose to try one of the anti-anxiety drugs (they don't work)."

First off, I am not a big proponent of (individual) dental "insurance:" in almost every circumstance, one is, at best, trading dollars with the insurance company. Think I'm off base? Do the math: waiting periods for anything more involved than a simple cleaning (and sometimes those, too!), deductibles and co-insurance for "major" claims, and an annual cap in the low $1,000's. Insurance companies miss very few tricks. Group dental is also a dollar-trading affair, but may make sense if some/most/all of those dollars are your employer's (if you buy into the theory that employers actually pay for insurance).

Be that as it may, our correspondent raises an interesting question: why is N2O not considered an eligible expense in this scenario? After all, novacaine is okay when you're having a tooth filled, and nitrous is approved for extractions, so why not here?

The easy answer is: because dental insurance is regulated very differently than medical coverage, and carriers can exclude a whole lot more in the former than the latter. Since a benefit that's excluded doesn't cost the carrier anything, there's an incentive to keep as much as possible off the "covered" list.

The more accurate answer is, as the email mentioned, "medical necessity." That is, "treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.” I might add that the industry has often expanded this definition, to include certain obvious comfort-making processes (i.e. anaesthesia for surgery, etc). One can readily see that, although our correspondent may well experience heightened anxiety when visiting her dental practitioner, this does not in and of itself constitute medical necessity.

One possible alternative for folks contemplating dental coverage is to look into an HSA compliant medical plan, and funding dental (and a host of other eligible) expenses through the tax-advantaged Health Savings Account. In this way, Uncle Sam is helping to subsidize your out of pocket, including the aforementioned N2O. And if you're able to shed some anxiety, the money then stays in your account, instead of going to the insurer.

A rather toothsome win-win.

Medical Necessity Redux

It's time once again to open up the can o'worms known as "medical necessity." This caused an interesting kerfluffle some years ago when we discussed it as regards IVF. Yet here we go, once more into that (metaphorical) breech.

Last week, Bob wrote about "free" prescriptions, and their true cost. In that post, he noted that the "Institute of Medicine wants women to get free birth control pills ... [w]ith some pills running $90 per month."

That's just shy of $1,200 a year for a "medication" with but one purpose, to prevent a potential consequence of an easily avoided behavior, and for which numerous other "therapies" are available.

Now, it's true that these "meds" are sometimes used for other purposes (eg endometriosis), but again, all of these alternative - "off label," if you will - uses are easily (and often more effectively) substitutable by other protocols.

To put it another way: there is no justifiable medical reason for birth control pills to be covered by insurance. And, quite frankly, asking the 50% of the population who gain no benefit from these little pills to subsidize their cost is unfair, and unjustifiable.

But there's a larger issue here:

"The Obama administration seems ready to force insurance companies to include birth control coverage in their plans. So much for the president's promise of bending health care costs downward."

In fact, it gives HHS Secretary Shecantbeserious the "authority to compile a list of female preventive services that all new health insurance plans will have to cover without employing deductibles or charging co-payments."

These are known as "first dollar" benefits, meaning that there is no deductible, co-insurance or co-pay required of the recipient. It's "free." So much for "skin in the game," as well: we already know what happens to costs when benefits incur no out-of-pocket costs. And again, who's punished by this?

You'll notice that I don't advocate that plans cover Viagra, or prostate exams, or Rogaine. At all.

Those, too, increase costs, and only one can be considered medically necessary. But if we're going to go down this road, how about a little fairness?

"Compassionate" Gummint Care

"Whomever pays the piper calls the tune" goes the (once-popular) adage. And that makes a certain amount of sense: if, for example, the government is paying for one's health care (which, of course, it's not; the taxpayer foots the bill), then the government has a stake in both the cost and outcome of that care.

I don't much disagree with that.

But that then begs the question of whether or not we should have the choice of opting out of such a system. As we've seen, when the gummint controls health care (and the funding thereof), it gets to "call the tune" in ways that folks may not have envisioned. Which brings us to the point of all these questions: if the gummint runs the health care system, does that mean it gets to override the advice and concerns of one's own physician?

It appears that it may, in fact, mean just that:

"Because of strokes she suffered while in her mother's womb, 13-year-old Callie Moore of Danielsville has a host of complex medical problems. ... Callie's condition mandates round-the-clock care and treatment. Under federal and state Medicaid regulations and policies, she is entitled to screening, diagnostic and treatment services and, because she is medically fragile, skilled nursing care ... Callie's doctor prescribed 94 hours a week of nursing services, but state officials unilaterally reduced the hours to 84 in 2006."

Now it's important to remember that the state didn't (and thus far, can't) prohibit Callie from receiving the extra 10 hours, but it can certainly refuse to pay for them. And so it has. Since I'm not a doctor (nor do I play one on TV), I won't pass judgment on whether or not the disputed 10 hours are "medically necessary;" but certainly when the state deems them not to be, it's very difficult to "fight city hall."

Now, astute readers may observe that insurance carriers also have a say in whether or not the cost of care will be reimbursed. And that's true: if you've ever filed a claim, you know that the insurer will "reprice" it based on the rates they've previously negotiated with the provider. And sometimes, they'll deny a claim (or pay a reduced amount) based on medical necessity.

But there are some important distinctions: first, the contract itself is agreed to by the parties (the insurer and the insured), they are subject to several appeals processes, and, ultimately, the insurer may be sued by the insured or even fined by the state.

Meanwhile, one can shop around for a different carrier.

There are, in short, choices.

A gummint-sponsored plan, however, offers few of these safeguards, and no choices. The plans are not flexible, one doesn't get to see a policy, and the insured has two choices: abide by the decisions or forego the coverage. An insurer may well have "deep pockets," but they don't have bottomless ones. Not so with the state, which has powers far beyond those of mere insurers.

Callie's parents fought the decision in court, and won. Instead of abiding by the decision, however, three states are fighting it:

"In March, Georgia, Florida, and Alabama joined in an appeal of a 2008 U.S. District Court ruling that a patient’s physician was better positioned – and better qualified – to make decisions about that patient’s medical treatment than state bureaucrats."

Again, readers may argue that insurers make these kinds of decisions, as well, and they'd be correct. But insurers employ legions of medical folks, from CMO's to on-call nurses, to help make them. The state doesn't. There's no question that insurers make bone-headed decisions (one has only to read our on-going Stupid Carrier Tricks series for proof of that); but they are usually held to account for them, and the state has the power to change those decisions, and to enforce those changes.

But who enforces the enforcers?

If the state is the sole source of medical insurance, let alone the sole source of medical care, then who or what has the means to hold those bureaucrats' feet to the fire? That's the danger of socialized, government-run health care, and little Callie may indeed be the poster child for refusing it.

ADDENDUM: In further proof of gummint-run healthcare's tepid sense of "compassion," there's this (from the Files of the MVNHS©):

"Health Service paramedics have been told not to resuscitate terminally-ill patients who register on a controversial new database to say they want to die."

Granted, this is at least a kind of "choice," but is it really the kind of change we really want?

ADDENDUM THE SECOND: Straight from the source, an important warning about the dangers of nationalized health care:

[Hat Tip: Elizabeth Terrell]

Nip/Tuck/Tax

Thinking about a tummy tuck? How about a facelift or "augmentation" surgery? Better think again:

"Face-lifts, tummy tucks and hair transplants could be hit with a new tax to help finance the trillion-dollar healthcare overhaul plan, according to sources familiar with the Senate talks."

One has to wonder, though, how an effort lauded as "deficit neutral" could give rise to so many proposed tax increases. Oh, that's right, by raising taxes, we can keep the deficit low. I'm no economist, but something about that equation strikes me as, um...unlikely.

Now, regular readers know that I'm very much taken with the concept of "medical necessity;"still, it never occurred to me that penalizing folks for those choices was a grand idea. But that's just what Congress is mulling:

"It would target procedures prohibited under Section 213 of the tax code, which deals with itemized deductions for medical expenses not covered by health insurance."

So, it's a hat-trick: not covered by insurance, hence not eligible for in-network pricing (discounts) and a hefty tax penalty to boot(y)? Is that part of that whole "soak the rich" mentality that's going to lower medical costs for the rest of us?

I didn't think so: a similar tax scheme in the Garden State yielded only about "25 percent of anticipated revenue since it was enacted in 2004 and imposes "another bureaucratic layer," including questions of how to determine what procedures are eligible."

Yep, just what we need: another "bureaucratic layer" is just the ticket to reining in health costs.

Sounds like a classic case of cranial-rectal inversion to me.

Potentially Useful Carrier Trick

Transparency in health care (both the delivery and financing of same) has been a recurrent theme here at IB. One of the problems, of course, is getting providers and carriers on the same page regarding what kinds of information should be available, and how to decide what information is useful. And although I've had my issues with AHIP, it seems that they may be able to deliver on at least one piece of the transparency puzzle:

"Eight of Ohio's major health insurance companies, which provide coverage to 91 percent of the state's residents, announced Monday that they have created a Web site that gives doctors one place to find patients' benefit information."

The insurers, working with AHIP and the Ohio State Medical Association (OSMA), have apparently developed a way to put coverage and claims information on-line, available to both the provider and the insured. There are a number of benefits to this idea; for one thing, it should help cut down on claims denials due to policy exclusions. That is, if an expense isn't covered, that information is available (almost) immediately to both parties. On the other hand, insureds with covered expenses can know from the outset how much their carrier will pay towards a given procedure, and the provider will benefit from knowing what their reimbursement rate will be. This could lead to more consumer-driven interaction, focusing on cost-effectiveness and medical necessity.

The provider benefits in a number of ways from this, as well: according to OSMA, medical office staffs spend over 3,000 hours a year just connecting with insurers. And the doctors themselves spend, on average, some three and a half hours every week "calling insurance companies and checking various Web sites to track billing claims and coverage." This new program promises to significantly reduce both those numbers. This benefits pretty much everyone: less time dealing with claims should translate to more time with patients or reading the latest journals.

I do have a few questions about how this program evolved, and how it's to be implemented, so I've emailed all three parties to see about getting some background. Hopefully, we'll have a follow-up post with more details.

[Hat Tip: Bob Vineyard, CLU]

MVNHS©: Like a Virgin

While the Much Vaunted NHS© has no compunction about withholding potentially life-saving cancer treatments, it's less sanguine about denying other "medically necessary" procedures:

"Women are being given controversial "virginity repair" operations on the NHS, it emerged last night.

Taxpayers funded 24 hymen replacement operations between 2005 and 2006, official figures revealed."

Regular IB readers may recall our IVF "kerfluffle" a few years ago: I fail to see where this process crosses the "medical necessity" threshold, either. It boggles the mind that this procedure costs upwards of $8,000 a pop.

The catalyst, and rationale, behind this sudden burst of medical activity appears to be cultural rather than medical. I have nothing against most religious practices, but I don't see why the taxpayer is required to fund them.

The MVNHS© has a history of acquiescing to a specific cultural bloc, which may explain why they've rolled over so easily on this issue, as well.

Disturbing News: Update

[Welcome Industry Radar and Insurance Forums readers!]

Regular readers know that we're nobody's shill; we regularly skewer carriers, providers, even fellow agents. But we also know that the "regular" media often fail to report (or even try to determine) "the other side." We saw it last year, with the sad story of Nataline Sarkisyan and CIGNA. And we're seeing it again now, with the equally sorry tale of Caitlin Jackson.

As it turns out, there's quite a bit of misleading information in the original news account. How do I know this? Because I spent a great deal of time on the phone late yesterday afternoon, working my way through Aetna corporate communications in order to give our readers a more precise understanding of the issues.

As it happens, I connected with a very helpful young lady, who remembered our earlier posts on Aetna's transparency program, and our interview with Dr Campinha-Bacote. This helped to establish our bona fides (literally: Fido's bones), and we learned a bit more about this unfolding drama.

Full disclosure: due to HIPAA privacy regulations, there were quite a few questions I asked for which the spokeperson could provide no answers. This may change as the case develops, and we'll keep you posted.

In the original story, it was reported that the surgery was initally approved by Aetna "15 minutes too late." While this makes compelling reading, and certainly casts the carrier in an unfavorable light, it was simply untrue, and the reporter knew it.

Let me repeat that: The reporter knew for a fact that there was no such process, and yet reported it as true anyway. According to Aetna, "under the plan, Aetna does not require pre-authorization for surgery so we neither would have pre-authorized or denied the surgery as portrayed in the Tampa TV news story." [ed: from email] Not only that, but Aetna "explained to the Tampa reporter that the scenario she was portraying of us "approving" surgery is not accurate because we don't pre-auth [pre-authorize], but she ran it anyway."

I also learned that "(m)edical necessity is not relevant to this conversation;" that is, there was no issue regarding the appropriateness of the treatment. As an aside, I think that's a mistake: as we've discussed before, "medical necessity" is a key component of health insurance, and would be relevant in ascertaining whether the surgery was even called for. Nevertheless, it wasn't in this case, and one supposes that Aetna is entitled to its own procedures.

There are apparently "other inaccuracies in the story as well," but my contact declined to identity them. Hopefully, that will change.

One final point: if we're going to have a meaningful discussion about the merits and shortfalls of our current health care financing system (and I think we should), then it's in everyone's best interest to do so in an honest, fact-based manner.

Well, maybe not everyone's.

UPDATE (7/18/08): Just received this email from my contact at Aetna:

"While I cannot share details, I thought you would want to know we have resolved this matter together with the hospital. We advised the member yesterday."

Good news!

CowPatty Alert: This is just self-serving; there is zero indication (or likelihood) that Ms Brooks' "efforts" resulted in anything other than sensationalism:

"After an extensive investigation this week by Tampa Bay’s 10 News, Aetna is now changing its tune and partnering with Tampa General Hospital to cover one hundred percent of the costs."

I need to take a shower after that.

IVF in the News (Again)...

Back in October we took a pretty extensive look at In Vitro Fertilization (IVF) and insurance. The underlying premise of that article was that “IVF fails to meet the threshold of “medical necessity,” ergo it should not be covered by insurance.”

Apparently, most employers (and their group carriers) must agree with that assessment, because

"Only 25% of employers offer any type of infertility treatment, and even some of that is not very comprehensive. They might just cover the diagnosis of a disease," says Julie Salz Greenstein, government relations director for Resolve, a national infertility advocacy group.

Ms Greenstein opines that “(w)e believe it's the right of people to try to build their families." Well, of course she – and her colleagues – are free to believe anything they’d like; the problem arises only because she apparently believes that it is also her right to force others to help pay for her treatment.

What bothers me about this attitude is that proponents of lifestyle-related benefits, whether they be for IVF or Rogaine, seem not to understand the underlying economic factors at work. For example, Connecticut recently became the 12th state to require coverage for IVF. This means that policyholders in Connecticut will now subsidize the cost of this expensive treatment, whether or not they want to do so. This effectively means that insureds will now see rates increase due to treatment for a lifestyle choice, not a medically necessity. Doesn’t seem quite fair.

Why, for example, would we cover IVF but not trans-gender or bariatric surgery? Both of these are lifestyle issues, as well, so why is it fair to exclude them? Each new covered benefit results in higher premiums. Is it Ms Greenstein’s contention that health insurance isn’t expensive enough? That doesn’t seem reasonable, or likely. But it is the end result of mandating coverage for treatments that are not medically necessary.

ObamaScrips©

As we reported last summer, those enrolled in tax-advantaged medical accounts (aka FSA/HSA/HRA) got a nasty surprise when we "passed the bill to see what's in it:"

"Health Savings and Flexible Spending Account (HSA and FSA) "funds can no longer be used to purchase OTC drugs and medicines ... unless you have a Note of Medical Necessity (NMN) or a prescription from your doctor."

We wrote at the time that this seemingly simple change "actually increases the cost of health care."

And we were right (of course):

"Patients are demanding doctors' orders for over-the-counter products because of a provision in the health-care overhaul that slipped past nearly everyone's radar [ed: not ours!] ... It drives up the cost of health care as opposed to reducing it," says Dr. Chung"

And of course, in classic "Rule of Unintended(?) Consequences" fashion, many physicians are balking at fulfilling these requests, further driving up the cost of health care (and hence, health insurance).

Told ya so.

[Hat Tip: FoIB Elena Marie]

Ch-ch-changes: HSA/FSA vs ObamaCare©

As if further proof were needed that ObamaCare© has little (if anything) to do with actual care, we learn from our favorite Flexible Benefits guru Pete Deist that, come January:

Health Savings and Flexible Spending Account (HSA and FSA) "funds can no longer be used to purchase OTC drugs and medicines ... unless you have a Note of Medical Necessity (NMN) or a prescription from your doctor."

In classic gummint fashion, though, one may (apparently) continue to use these tax-advantaged dollars to purchase non-medical items (such as contact lens supplies, batteries for hearing aids, etc). This just underscores how out-of-touch our CongressCritters really are. This is especially egregious when it comes to HSA money, since these types of plans are the only ones which actually impact the cost of health care.

The other "alternative benefit," HRA ([Health Reimbursement Arrangement], is similarly curtailed. And it's also worth noting that, come 2013, the cap (maximum contribution limit) on FSA's is reduced to $2500, a 50% reduction in this valuable benefit [Correction from FoIB Alissa C: "health FSAs currently have a federal cap of earned income (essentially no cap). It's currently up to the employer to set the maximum. $5,000 is the maximum for dependent care if single or married/filing jointly." HGS].

The real problem here is that this actually increases the cost of health care, in direct contradiction to the stated purpose of ObamaCare©. It makes less expensive treatments less affordable, and actually requires additional office visits (which aren't free) in order to buy Over-The-Counter med's. Sure glad we "passed it to see what's in it."

Aren't you?

[Hat Tip: FoIB Suzy R]

Tranny Deduction

Consumer driven healthcare has generally been about price transparency and patient empowerment. We've talked about various tax advantages inherent in "alternative benefit plans" like FSA's and HSA's. These advantages flow from an IRS document (213d) which delineate what's "kosher" for such reimbursements.

Obvious expenses include prescription med's, non-reimbursed office visits, even orthopedic hosiery. Obviously non-eligible expenses include hot tubs* and ski trips to Aspen.

But what about sex-change operations?

[ed: Hunh?]

Well, hip replacement surgery is okey-dokey, as is breast-reconstruction following a cancer-related mastectomy. Wouldn't it follow, then that gender-realignment procedures would be eligible for consideration?

Well, according to those neanderthals at the IRS, the answer is "no:"

"(A) 57-year-old suburban Boston man underwent a sex-change operation. Then she [he?] wrote off the $25,000 in medical expenses on her [his?] taxes.

But the IRS disallowed the deduction — ruling the procedure was cosmetic, not a medical necessity — in a potentially precedent-setting dispute now before the U.S. Tax Court."

And there it stands; the gentleman, er, lady in question has sued the IRS, seeking to have the substantial cost of the surgery made eligible for special tax treatment. The IRS maintains that this is elective, cosmetic surgery; the plaintiff argues that it's medically necessary.

Should make for some fascinating Court TV.

[*See comments for an update]

That Word Doesn’t Mean What You Think It Means

What do you think of when you hear the word emergency?

According to Webster’s Dictionary an Emergency is “an unforeseen combination of circumstances or the resulting state that calls for immediate action.”

However, insurers in Minnesota think it means something different.

“Minnesota lawmakers are seeking more transparency from air ambulance companies about the prices of their rides, according to the Post Bulletin.”

Why would lawmakers be interested in making these prices transparent, since the only time you would use an Air Ambulance is in an Emergency?

Because customers have received “surprise air ambulance bills …from insurers that have denied claims for emergency transport, saying the rides weren't preauthorized or weren't necessary.”

I have seen my share of unwarranted denials, but this takes the cake. In an emergency there is no time to get a Preauthorization. A Preauthorization is usually required for any type of surgery, lab, test, or medication that will require a significant reimbursement by an insurer. Preauthorization’s can take anywhere from 48 hours to weeks to obtain. Obviously if you are bleeding on the side of the road and will die without immediate medical coverage you cannot wait for a Preauthorization.

As to the necessity, once again, it is self-evident.

It is this idiocracy of thinking by insurance companies that hinder medical decision making. While this is an extreme of insurance meddling in medical decision making, this interference occurs hundreds of times a day in every medical facility across the nation.

The Flipside of Empowerment...

We've blogged a lot here about transparency and consumer empowerment. And those are key components in the drive toward more consumer-centric health care. Mostly, of course, we talk about availability and cost of services, versus medical necessity and consumer driven health plans.

We also tend to post about our own experiences: with clients and carriers, both good and bad (mostly the latter, since they tend to be more interesting). We're always careful to anonymize the "innocent," because names aren't nearly as important as circumstances.

And we're not alone: the "medblogosphere" is lousy with health care providers (doctors, nurses, surgeons, you name it). And they, of course, have their own resources and places to post about difficult cases or patients. But what if they post what my daughters call "TMI" (Too Much Information)?

Good question:

"Hundreds of doctors across the country are writing Internet diaries that sometimes include harsh judgments of patients, coarse observations and distinct details of some cases."

That's quite a thin line: too little information, and you're not going to get much helpful feedback. Too much, and you've breeched confidentiality. So where is that line? Who draws it? Who decides whether or not it should be drawn at all?

We've got it pretty easy here at IB: since we post about cases simply as examples of either good or bad behavior, we're not really looking for advice on how to handle a given scenario. Mostly, they're just ways to illustrate a particular insurance principle or plan.

But the doc's often use their blogs as sounding-boards, and this can be a problem:

"One of the fundamental aspects of medicine is that patients have to feel free to tell doctors everything," said Dr. David Stern [ed: no relation], who teaches professionalism at the University of Michigan Medical School. "They're not going to tell us everything if they're asking themselves when they come in to see their physician, 'Is my doctor going to blog about me?"

When we get mail asking about a particular concept or problem, I usually ask for permission to post the email and my response, and I scrub out identifying details (they're really not necessary to make my points). Most of the time, the answer's yes. Sometimes, there is no answer, which I take as a tacit "yes." So far, no one's told me "no," but I'd certainly respect that it if came up.

Something to think about.

Oh Baby, Baby!

The LA Times has this breathtaking lede:

"Before Joanna Joshua and Kyle Winning started a family, they hunted for health insurance to cover the increasingly high cost of having a baby."

Let's reword this, shall we?

"Before Joanna Joshua and Kyle intentionally burned down their house, they hunted for homeowners' insurance to cover the increasingly high cost of rebuilding it."

There, isn't that better?

Of course, both circumstances are silly, but they underscore the principle of risk. Being pregnant is not a disease, and it is easily avoided (we'll leave rape out of the equation, since that is, in fact, an unforeseeable risk). Insurance companies know this, and know that the utilization rate for maternity riders approaches 100%. That's not risk, that's cost-shifting. So to the extent that such riders are available at all, carriers price and configure them to essentially refund (at best) the premium paid.

Here's where it gets dicey, though:

"The dearth of choices forces many would-be mothers into government insurance programs paid for by taxpayers ... All of this drives up costs for hospitals, insurers and consumers buying individual policies."

It's a heads-I-win-tails-you-lose proposition: folks see no problem with mandating birth control, and also want coverage for having a baby. Neither of these pass the test of "medical necessity," and both of them drive up health care costs for everyone. The result? Even more uninsured:

"The industry's trade group, the Assn. of California Life and Health Insurance Cos., pointed to a study that found the most recent maternity bill in Sacramento would drive up insurance rates as much as 28%, and would prompt more than 9,000 mostly young policyholders to give up their insurance."

But don't we want more people to be insured, not less?

Transjenner Insurance

Bruce Jenner may be the celebrity-du-jour of the transgender set, but he's certainly not the only member of it. While he and his extended family can most likely afford to pay for the procedure(s) out-of-pocket, most folks lack the requisite funds to do so.

And just how much does this process cost? Well:

"The total typical cost of a transition usually includes: expenses incurred in the year before surgery, during which hormone therapy, counseling and living full-time as the target sex are recommended; the cost of the surgery and follow-up care; and ongoing costs after the surgery, including hormone therapy for life and continued doctor visits."

All told, a successful (for certain values of "success") transition seems to run between $40,000 and $50,000. That's a lot of scratch for a non-celebrity, so to what other source might one turn for help?

If you thought "health insurance," give yourself a cigar (preferably a candy one: tobacco use results in higher insurance rates). Now, you may be thinking "Henry, I understood that health insurance covers only medically necessary procedures; how can this possibly fit that bill?"

And you'd be right again.

Sorta:

My initial reaction was "no way a health insurance policy covers this."

But then alert reader and FoIB Jeff M sent me this gem:

"Obamacare to cover majority of transgender woman's sex reassignment surgery costs ... with the help of Obamacare, Larson says she is looking at paying $5,000 out of pocket for the surgery."

Surely that can't be right: what carrier in its right mind would cover such a thing?

Turns out, more than a few: Aetna, Anthem Blue Cross Blue Shield, Cigna and several others cover the surgery (or surgeries), subject to a very specific definition of medical necessity. Interestingly, UHC generally doesn't.

And those plans that do offer coverage treat it the "same as any other illness;" that is, subject to deductibles and co-insurance, as well as any network pricing issues. So depending on what plan one has, out-of-pocket could be as little as a few thousand dollars. Reason #4,835 why premiums are skyrocketing.

Ah, what brave, new world.