MEDICAL DECISIONMAKING: Empire Program ‘Deeply’ Involved
Empire Blue Cross & Blue Shield of New York has launched a "controversial" new cost management program that some are saying oversteps the bounds of appropriate insurer involvement in medical decisions, the Wall Street Journal reports. The company rolled out its "Systematic Analysis Review and Assistance" program earlier this year to 430,000 of its 4.1 million members, about half of whom are covered under plans it administers for large, self-insured firms. Under the program, Empire reviews patient records for "potential treatment problems that could cause medical complications," such as adverse drug interactions. The company than calls the physician in question and suggests a change. If the physician "refuses to correct a clear-cut error," the Journal reports, Empire calls the patient directly to warn of the potential danger.
Not surprisingly, some patients worry that this involvement will compromise their privacy. "Big Brother is watching you, I guess," said one 38-year-old diabetic, who admitted he is "probably better off because Empire called his doctor to say he was long overdue for a checkup with an ophthalmologist." Empire President and CEO Dr. Michael Stocker says the company is addressing the privacy concerns by "promising never to use any information to deny coverage or raise premiums," as well as by alerting enrollees to the program and allowing them to opt out. Only about 100 have done so, the Journal reports.
Empire's program is similar to disease management programs instituted by many HMOs in the last decade to monitor cost and quality. The Empire, program, however, "cuts across all illnesses," selecting patients at high risk for "calamitous" events "based on hundreds of potential red flags." It also goes a step further than other HMOs by having an Empire medical director run interference, as necessary, with the patient's doctor. New England Journal of Medicine Editor in- Chief Emeritus Dr. Arnold Relman says that while the program "may help catch physician lapses," he believes local physician groups are better suited to conduct such reviews. Relman also warns that HMOs that get involved to such a degree should be held responsible in court for the consequences of their medical decisions. The Journal reports that Empire's Dr. Stocker "says he is aware that the program may pose added legal risk." All told, however, the company believes its new program "will pay off in better patient care and millions of dollars in savings and avoidable health costs" (Jeffrey, 5/21).