Hold It, Doc, We Won’t Pay for That : Insurance: Who is to be the ultimate authority on treatment--the heretofore sacred alliance of doctor and patient or a faceless cadre of executives?
Your health is being threatened from an unexpected direction: your insurance company. As we become accustomed to the dangers of pollution, overcrowding, radon and nuclear waste, it becomes increasingly vital to examine health-care decisions being forced on us by some insurance companies. Certain companies will go to any length to avoid paying legitimate claims for new and innovative treatments in a timely way. Much of the dilemma falls on people with life-threatening diagnoses, such as cancer, hemophilia or AIDS.
Physicians and hospitals have the professional and moral obligation to keep abreast of evolving medical technology and prescribe new treatments as soon as they are deemed safe and effective by the Food and Drug Administration and prevailing standards of medical practice. To do less would be to practice substandard medicine and to raise the specter of malpractice. However, certain third-party payers, such as Prudential and California Blue Shield, have institutionalized a policy of disallowing payments for life-saving treatments. This policy is based on a narrow interpretation of FDA guidelines, and forces policyholders to settle for less than the best available treatment.
Nowhere is this Catch-22 more obvious than in the areas of HIV medical care. FDA-approved drugs AZT and Pentamidine have been widely accepted as prolonging life and improving the well-being of tens of thousands of infected people. Since these new treatments are most effective for people whose immune systems are least-impaired, early intervention has become the national standard among AIDS specialists.
However, if you are unlucky enough to have California Blue Shield or Prudential health insurance, necessary treatments will not be covered unless your immune system is frighteningly impaired, regardless of your physical condition and no matter what the doctor recommends. The argument used by these companies is that the drugs’ labels recommend AZT and Pentamidine only for people with very weak immune systems.
According to former FDA Commissioner Dr. Frank Young, “The FDA does not believe that approved drug labeling reflects the sum total of all medical, scientific knowledge regarding the use of a given drug. Nor should the labeling be construed to circumscribe the practice of medicine with regard to all possible uses of the drug under all circumstances. Clinical research is dynamic, and new information is constantly generated. The Food, Drug and Cosmetics Act does not limit the manner in which physicians may use an approved drug.”
However, to try to save money, your insurance company may not cover using drugs in a new way.
No longer can one think that early intervention with medical treatment serves no useful purpose in stemming the onslaught of AIDS. Since mid-1987, when AZT and Pentamidine became available, there has been a steady decline in the number of expected cases of AIDS and a decline in the projected death rate, specifically because of medical treatment. A few dollars spent early on can keep people well indefinitely and not only saves lives but also larger medical expenses later.
The broad issue can be reduced to the question of who is to have the ultimate authority in deciding questions of treatment: the heretofore sacred alliance of doctor and patient or a faceless cadre of insurance company executives who care more about saving money than saving lives. If the insurance industry is allowed to continue to play the role of the prescribing physician, the inevitable question arises: to what extent will insurance companies expand their medical meddling? Will they continue to usurp the physician’s role in diagnosing, prescribing and treating Americans’ ills?
Unfortunately, in the case of AIDS patients, the insurance claimant is rarely alive long enough to sustain a lengthy legal battle. Death is often the ultimate result of insurance company intransigence. Arbitrary guidelines, administered by low-level clerks and flying in the face of precedent-setting “prevailing standards of care,” must cease. We cannot let our insurance companies go into the business of practicing medicine.
Today the issue is AIDS; tomorrow it may be cancer, heart disease or a host of other life-threatening illnesses that all of us in our aging society will continue to face as the years pass. And, when we turn to our medical insurance companies for our financial needs, where will they be?
