Judging the Judges: A Special Comment

Posted by fxckfeelings on September 14, 2009

The not-MD here: Now that an actual health care bill is almost upon us, I thought this would be a good opportunity to ask my writing partner, as an actual health care provider, for his take on how we can improve health insurance.

We don’t like to get political, and everyone’s entitled to their own views (at least I think so—he’d probably tell you you’re just wrong), but this is not an entry about politics; at its core, the health care debate is about health care, and as a doctor, not a Democrat or Republican, this is his medical point of view. We’ll return to normal cases on Thursday.
–Dr. Lastname

One thing you learn as a parent is that there’s never enough time, money, or resources to provide perfect safety and security for your family. Worse, if you hold yourself responsible for providing it, you’ll go nuts the first time something goes badly wrong and you can’t control it. You’ll blow everything on something that can’t be helped, feel like a failure, and have nothing left, financially or emotionally, for those who need you.

As such, compromising on how you spend your resources is as much a part of good parenting as is nurturing, although it often makes you feel terrible. So it is with health care systems.

Democrats sometimes emphasize the nurturing part of this process, our shared humanitarian desire to provide more care, while Republicans sometimes emphasize the tougher part of this process, our desire to make sure that treatments work and are well delivered. But at the heart of good management there is always an unavoidable need to make good compromises, and that’s what I think needs more attention and reform. Not fewer denials from the insurance companies, but denials that are more fair and decided upon more ethically.

That might sound harsh, but remember, we will never have enough money for everyone to have unlimited access to the most expensive treatments, and if we focus too many resources on patients’ problems that aren’t likely to get better, we’ll leave ourselves broke and with nothing to give those who might really benefit.

Making resource decisions on a case-by-case basis is called utilization management, and it’s done by most managed care insurers and many public care systems. Without utilization management, too much care goes to the person who is first in line or has the best advocate, leaving the rest on a waiting list.

It’s the job of the utilization manager to review a patient’s case on behalf of the insurance company and judge whether the requested treatment is medically necessary and therefore eligible for coverage. It’s never easy for a utilization manager to say “no” to requests for care, but the process is better than the alternative.

For a managed system of health care to work, the resource decisions of utilization managers must ultimately have integrity and inspire respect, like the decisions of judges. They must be impartial, arise from clinical and ethical principles, stand up to scrutiny, and undergo revision through an appeal process. Yet this is not the case.

Currently, this process of utilization management has insufficient safeguards protecting medical/clinical resource decision-making from being overly influenced by business incentives. For instance, there is nothing to stop an insurance company (or government, or hospital) executive from saying to utilization managers who work for him or her, “we have too many patients in the hospital today, you need to tighten up on your admissions reviews and not agree to so many admissions.”

It should be unlawful for non-clinical executives to urge utilization managers to take its financial condition into account when making resource management decisions—it’s certainly unethical—but it happens all the time.

And if insurers believe a particular reviewer is too “lenient” in making decisions, it can steer these decisions to another reviewer the company thinks is tougher and less likely to consider a costly treatment as necessary. Almost always, the insurer pays the salary or fees for the managers who make these decisions, as well as for “the higher court” of managers who review appeals of these decisions.

So the insurer can always choose utilization managers to make decisions that it, the insurer, thinks are best, and if there’s a dispute, they’re also paying additional managers—the second tier of judges—who make the final call. Naturally, most executives and utilization managers strive to be fair; but the lack of safeguards has an insidious and negative effect on the decision making process.

So here’s what I think doctors and patients need to do. Accept that utilization management is unavoidable and needs to be done right, working together to protect the integrity of the decision-making system.

Let me tell you, my fellow doctors: our leadership on this is needed and has been sorely missed. And let me tell you, my patients: you can’t avoid an oversight system, so put your energy into insisting that it get fairer and more impartial, not limitless. It needs a common set of regulations, publicly arrived at, and a method of funding that guarantees the independence of its judges, at least at the appeal level.

There’s no avoiding compromise, not in health care decisions, not in life in general. We need to clean up the utilization management system by which compromises are now made. We should aim for systems that make good, ethical compromises, not that give perfect care or that punish the current crop of resource wasters. And then our reforms will be lasting and create a system that does the right thing.