Principles of Action
I. Managed Care: The Rationing of Medical Care
Medical science, aided by the basic sciences of molecular biology, molecular genetics, and immunology has advanced with unprecedented speed in the past few decades. The biotechnology economy has generated a host of new diagnostic tools, imaging devices, and treatment modalities, which have moved from research to state-of-the-art status in a matter of months. At the same moment that new treatments have changed the natural course of illnesses, the costs of these advances threaten the way medical care is delivered.
The health insurance industry has historically operated on the principle that statistical analysis of populations allows one to predict the frequency of medical needs among groups of people. These predictions, coupled with historical data about the costs of medical care allow pooling of health care dollars by insurers, who then distribute funds to those unfortunate enough to need health care services. Based on this model, the industry knows a great deal about groups of patients, but nothing about the medical needs of individuals. It is thus axiomatic that the insurance industry has no legitimate role in the medical management of individual patients.
Growth in health care expenditures has outstripped the growth rate of our economy by multiples of ten in some recent years, as one might have predicted by the growth of medical knowledge. This has led to a fundamental change in health care delivery for everyone who depends on health care insurance. Rather than adhering to the standard actuarial model of assuming risk, insurers have opted to manage the practice of medicine. Specifically, the industry has invented managed care strategies to ration medical treatment. Medical care is rapidly becoming less about the expertise of ones doctor, and more about how aggressively ones insurance company wishes to control the behavior of that physician.
Arguably one of the most intrusive practices of the managed care approach is to require prior authorization for medical therapy. This practice assumes that an insurance business has the capacity to judge what is medically appropriate without being influenced by the issues of cost. It is difficult to imagine a more profound conflict of interest. This practice further assumes that a non-physician (often a nurse or pharmacist) can be trained to review medical records and reach some sort of informed judgment about the nature of the illness, the severity of disease, and the appropriateness of treatment, all without the benefit of ever seeing the patient. With all due respect to the many health care professionals employed by the heath insurance industry, this is not a rational expectation. Nevertheless, well-intentioned health care professionals are paid to support and defend a system that rations medical care with inadequate professional standing, free of any personal obligation to the patient, and with no responsibility for the consequences.
This rationing of medical care is difficult to recognize, because physicians do have the option to obtain approval for treatments. To obtain prior authorization for treatment, a physician must commit practice resources to filing requests, sending copies of medical records, time-consuming telephone calls to expedite action, letters of medical necessity, and tracking responses from dozens of insurers. These activities do not contribute to the quality of care delivered, but merely force physicians to hire staff who work solely for the benefit of the insurance industry. The result is an arbitrary work barrier that discourages a physician from choosing therapy that is otherwise in the patient's best interest. Thus, an industry with no medical expertise or responsibility can drive the level of health care to the lowest level that society (or the marketplace) will tolerate.
Rheumatologists are specialists trained in the clinical practice of medicine with expertise in the recognition, evaluation and treatment of arthritic and inflammatory disorders. Credentialing of specialists in this field requires completed training in Internal Medicine, followed by at least two additional years of study in an approved Fellowship training program, and successful completion of Board Certification by the American Board of Internal Medicine. Rheumatologists are universally recognized by all other medical and surgical specialists as essential to the care of patients with rheumatic diseases.
Recent medical advances in the treatment of Rheumatoid Arthritis and other related illnesses have thrust the Rheumatology community into direct conflict with the rationing strategies of managed care. Biologic response modifiers are among the first fruits of the biotechnology revolution, and have been proven to provide patients with unprecedented levels of efficacy, safety and protection from progressive joint damage. Rheumatologists recognize that these agents will not merely relieve pain, but will in many cases put patients into remission; able to work, support their families, and avoid the disability that often follows joint damage. The costs of these agents are high, making them a target for management. Consequently, Rheumatologists are now required to request prior authorization for these treatments. This requirement assumes that the insurance carrier has medical expertise, which is not the case. Medical directors employed by the company may review cases, but the practice of making medical decisions with no direct patient assessment undercuts the illusion that the decision is made on medical, rather than on financial grounds. In the final analysis, efforts of the health insurance industry to manage medical care provided by specialists have no medical legitimacy.
Physicians have several responsibilities to patients, including a primary obligation to do no harm, and an obligation to act as an advocate on their behalf in medical matters. Physicians who choose to fight this rationing system on a case-by-case basis rapidly lose their enthusiasm for jumping through the hoops that question their competence, or simply consume valuable time that is better used caring for patients. Advocacy efforts for patients are more effective when assumed by professional medical organizations on a societal level, identifying this threat to the quality of care and making aggressive educational efforts directed at both purchasers of these plans and the public at large. The Oregon Rheumatology Alliance is dedicated to this form of patient advocacy.
II. Pharmaceutical Market Manipulation
Another outgrowth of the managed care industry has been a predictable effort on the part of the drug makers to control their market. As insurers have assumed the role of managing medical therapy, drug makers have begun selling to insurers and hospitals, negotiating preferences for their drugs, in return for discounted prices. It should surprise no one that pharmaceutical companies can purchase drug preference by offering an adequately large discount. This practice magnifies the financial conflict of interest and further distorts the delivery of medical care by enlisting an insurance company to encourage use of one drug over another. This business practice is fundamentally unethical: there is no defensible rationale for financially driven formulary preference. Physicians should use any and all organizational mechanisms to expose and condemn this practice. ORA condemns this practice.
February 26, 2003