INSURANCE COVERAGE: Doctors, Insurers Often Disagree
There is a "deep discord between physician recommendations and insurance coverage decisions," according to a study in today's Journal of the American Medical Association that focused on physician recommendations for the use of growth hormones (Finkelstein et al, 3/4 issue). "About 1 million children are short enough to be considered candidates for growth hormone therapy. Insurers, however, say only 25,000 or so actually have medical conditions that merit payment of this expensive treatment," NPR's Bob Edwards reports ("Morning Edition," 3/4). The JAMA study found that while doctors recommended GH therapy for 78 out of every 100 children suffering from GH deficiency, Turner syndrome or renal failure, insurers denied coverage to 28% of those children. Further, for children suffering from only Turner syndrome, a disease which stunts girls' stature and prevents their ovaries from developing, doctors recommended GH treatment in 96% of the cases, while insurers covered the treatment in only 52% of these cases (3/4 issue). "We found that there were disagreements between doctors' recommendations and insurers' coverage decisions. As a result, many children who might be recommended for growth hormone therapy by their physicians would be likely to have difficulty actually obtaining insurance coverage for the treatment," said the study's senior author, Dr. Leona Cuttler of Case Western Reserve University ("Morning Edition," 3/4).
Who's To Blame
The Boston Globe notes that what is still unclear "is whether doctors are overtreating or insurers are being stingy." Doctors frequently recommend the treatment that they feel will increase children's quality of life. "It upsets us when we truly feel there is an indication for treatment and someone else thinks it's not indicated. This is what we're trained to do," said Dr. Laurie Cohen, a pediatric endocrinologist at Boston-based Children's Hospital. The Globe reports that insurers, however, "point out how costly growth hormones can be, costing $15,000 or more a year, requiring continued use up to 10 years, and not always providing the desired result."
To make matters worse for the insurers, there is "no clear standard of what the appropriate level of care is" (Tye, 3/4). "Each insurance company has to make up their own mind based on the literature as to how they're going to proceed. And I think that is part of the way medicine develops in this country. And unless we appoint a supreme dictator, I really don't believe that's going to change in the near term," said Dr. Joseph Burman, chief medical officer of Anthem Blue Cross Blue Shield. Agreeing that there is considerable confusion when it comes to insurers covering treatment, Cuttler said, "I think at this point it seems like a black box in which requests go in for treatments and they're accepted or they're denied. And there's a sense of vulnerability, or lack of empowerment" for families ("Morning Edition," 3/4). "'[A] dialogue' on rare conditions, treatment and coverage is long overdue," she said (Ricks, Newsday, 3/4).
Short, Not Sick
The St. Paul Pioneer Press reports GH therapy "has been controversial because of medical disagreement and because manufacturers in past years marketed the treatment unusually aggressively, even sponsoring height screenings in schools." Clouding matters even more, doctors sometimes recommend GH treatment for children who are short, but have no medical problem. "We would say, based on our medical policy, that being short, per se, is not a disease and therefore should not be paid for through a health benefit," said Burman ("Morning Edition," 3/4).
Time To Act
The JAMA authors conclude that "the discrepancy between physician treatment recommendations and insurance coverage, exemplified by the current findings, constitutes a critical challenge to health care delivery with serious ramifications for access, costs and outcomes" (3/4 issue). In an accompanying editorial, Dr. James Sabin, codirector of the Center for Ethics in Managed Care says "researchers [need] to clearly establish whether the procedures work" and the "public [needs] to decide whether they are worth paying for through insurance premiums and taxes" (Globe, 3/4). If insurers and managed care organizations -- who fear that disclosing their rationale for covering or not covering ailments will be used against them -- do not start disclosing this information, it "will only engender more distrust and ensure additional backlash," Sabin writes (JAMA, 3/4 issue). "With an aging population and rapidly developing technologies, the policy questions around growth hormone are the type of policy questions we as a society are going to be facing again and again and again," notes Sapin. This debate "will only intensify as medicine develops new treatments for improving the quality of life" notes NPR's Judith Graham ("Morning Edition," 3/4).