Free market proponents have long argued that government involvement in health care ultimately leads to rationing. Bureaucrats at the Health and Human Services Department (HHS) are now proving them right by allowing partnered insurance companies to interfere with the recommendations of doctors without safeguards or patient protections.
The new policy, dubbed "fail first," permits insurers to force Medicare patients to initially try a cheaper treatment course, only paying for their doctor's original plan if the first treatment fails.
This new "policy" raises a range of troubling questions, including:
¦How many patients will suffer painful or adverse side effects from cheaper medicines when insurance companies overrule doctors to pad their bottom line?
¦Why are insurance companies being empowered to insert themselves into the medical process?
¦What about patients who die or suffer adverse consequences while they are "failing first"? What recourse do they have when their insurance company's medical judgement was elevated over their doctor's?
The policy will affect the Part B payments of all Medicare Advantage patients, which includes one-third of all Medicare beneficiaries. Medicare Advantage works by allowing enrollees to pick a plan administered by an insurance company that is subsidized by the government. Part B payments are for drugs administered directly by doctors or outpatient facilities -- which are the types of drugs least likely to be administered for any reason other than urgent medical necessity.
The American Medical Association (AMA) and hundreds of other patient and provider groups have excoriated the proposal, from HHS's Center for Medicare & Medicaid Service (CMS) and given the Orwellian name "step therapy," warning it will put patients' lives at risk.
"For cancer patients, selecting the proper personalized treatment as quickly as possible can be critical to survival," the AMA and 44 other national medical associations wrote in one letter criticizing the proposal.
Even ignoring for a moment whether it's a good idea in general to let insurance companies interfere with patients' care in this way, medical groups sounding the alarm about the policy have found serious flaws in its implementation, such as:
- CMS imposed essentially no boundaries for how this authority might be used.
- Insurance companies aren't required to notify patients if they've interfered with their treatment plan for cost-cutting purposes, and patients may not even be able to find out if they suspect it.
- There are no safeguards for patient safety or abuse by insurance companies.
- Insurance companies are not required to publicly report aggregate usage of "fail first," leaving the public in the dark about how often this happens in practice.
- The appeals process for patients seeking to overturn a "fail first" decision by the insurance company is stacked in favor of the insurance companies, requiring onerous paperwork to even file an appeal.
- Doctors aren't provided means of overriding the insurance companies' decisions in medically urgent circumstances.
Other critics have noted that the policy creates a Medicare Advantage "ghetto," where patients may receive worse care than other Medicare enrollees. That's especially regrettable given that Medicare Advantage, enacted by George W. Bush in 2003, has been a significant conservative health care policy success.
Meanwhile, the HHS Inspector General had already flagged the behavior of Medicare Advantage insurance providers as "concerning," warning of evidence that the companies were routinely and systematically rejecting payment claims that should have been provided.
An appeals board that arbitrates these coverage disputes ruled against the insurance companies an overwhelming 75 percent of the time, suggesting many practice a “deny first” approach. "This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment," the OIG wrote in a September 2018 report.
Between 2014-2016, only one percent of patients appealed, the OIG found, prompting concerns that the appeals process itself was overly burdensome to patients.
To summarize, insurance companies were already defrauding patients before they had "fail first"-- just imagine what they'll be able to do with CMS' blessing to put patients through uncomfortable and lengthy frivolous treatment plans before finally agreeing to what the doctor says!
CMS needs to pull this plan from the shelves, STAT. Putting insurance companies in between patients and doctors will create a significant amount of suffering. Patients will die. Others will be forced into an endless, Kafkaesque appeals process just to get adequate care. And in the process, CMS will turn Medicare Advantage into a Medicare ghetto, rolling back significant progress toward advancing patient choice and quality care.