Medical Care: Who Decides?
A maze of players determine insurance coverage of medical procedures
America’s health care system is a bit of a mess.
For-profit providers, insurance companies, pharmacy benefit managers, and others all play a role in the cost of care - and even in deciding what care is offered.
A new ProPublica story addresses the issue of prior authorization.
That’s the process by which an insurance company determines whether or not it will pay for the care or treatment recommended by a doctor.
Insurance companies say prior authorization is necessary to prevent expensive and unproven procedures.
Physicians say it can be a nightmare to navigate and prevent patients from getting the care they need.
Who decides what procedures are covered?
ProPublica:
Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations. Call it the denials for dollars business.
The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers — about 1 in 3 insured people. It is owned by the insurance giant Cigna.
When coverage is denied, patients could opt to pay for treatment themselves. This, though, is often prohibitively expensive.
Alternatively, doctors can try again. Or recommend a new (often cheaper) course of action. Even if that course of action will not likely benefit the patient.
Patient advocates and doctors say companies like EviCore lead to a lower quality of care and delays in patients receiving necessary or helpful treatment.
A company removed from the insurance company which itself is removed from the doctor-patient relationship makes a decision on who gets what treatment paid for based on a computer model.
That’s the system we have.
Add that to a system that also often leads to crippling medical debt, and it’s a wonder there isn’t more and louder clamoring for Medicare for All.
