On Point: Who gets to decide what works?

By Stanley Hupfield

The Daily Record Newswire

Much of television drama is fairly inane. Every now and then (probably without knowing it) television gives us a story line that is actually quite compelling. Recently I watched one of those lawyer shows — the type that portrays the principles defending the downtrodden against the vicissitudes of modern society and callous corporations. In this lawyer show the legal heroes were engaged in a lawsuit against a medical insurance company over their refusal to pay for an experimental procedure on a fetus in utero.

The insurance company’s denial was based on a central issue. The procedure in question was clearly experimental and thus not covered by contract language. Naturally, the insurance company was portrayed as mean-spirited and corrupt. We all know it is easy to hate insurance companies — which is, of course, why the president changed his call from health care reform to health insurance reform. The whole point of the drama was to position the couple fighting for their rights, the brave surgeon willing to try this highly controversial procedure, and the crusading attorneys against this profiteering, uncaring, corporate monolith.

But despite our outrage, let’s think this through. First, the relationship between the insurance company and its customers is contractual in nature. Party A pays Party B for insurance coverage under certain conditions. These conditions are generally clearly defined in the policy. Theoretically, by paying the premiums, Party A agrees to abide by and to be limited to those conditions. For the purposes of this drama, the policy stated that experimental procedures (which this clearly was) were noncovered services. So, by contract, the insurance company was within its rights to deny coverage.

Here is where it gets interesting. Insurance premiums are based largely on the losses the company incurs over time. So taking the emotion out of the equation, the case can be made that we actually want our insurance carrier to strictly follow policy language. We want our carrier to only pay for what works and what has been proven to work. To not do so ultimately only increases our own premiums.

The president has clearly said that in the future if we want to control health care costs, we must only pay for what works. By implication someone must decide what works — what is clinically effective based on the best medical evidence. So who gets to decide? Conservatives would argue that all health care decisions should only be between the doctor and the patient. This position has unquestionable appeal and a certain logic to it. It speaks to our sense of personal worth and our ability to control our own destiny. For as long as our nation has had health insurance available, many of us have enjoyed this freedom. It could be argued that this very freedom to get whatever we want, when we want it from a medical system and then have someone else pay the bill is exactly what produced a health system out of control.

So we are conflicted. We don’t want anybody to get between us and our doctor and our freedom of choice. The harsh reality is that this very freedom threatens the collapse of the whole system as costs continue to spiral out of control. The truth is we as the collective whole should applaud an insurance company that denies payment for procedures that do not meet the criteria for safe and effective medicine. That applause would, of course, end if it affected us personally. So our conclusion is that some insurance companies are clearly guilty of very egregious practices that stir the outrage in the public arena. This is contested with our own outrage over high premiums that only get worse in an environment where every doctor and every patient get to have whatever they desire. But perhaps my perspective is distorted by watching too much TV.

Stanley F. Hupfeld is the chairman of the Integris Family of Foundations. He is a fellow of the American College of Healthcare Executives.