A Better Way

Last week, the CBS news show, 60 minutes, in its normally breathless, muckraking manner, aired a segment entitled “Denied” which highlighted the review of psychiatric admissions by the insurance industry. It started with the statement, “When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others.” In the words of Scott Pelley, “The insurance industry aggressively reviews the cost of chronic cases.  Long term care is often denied by insurance company doctors who never see the patient.  As a result some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.”  The segment goes on to tell the stories of people who have either died or come close to death due to these decisions.  It also reviewed the process of making these denial decisions and presents them as cavalier and potentially uncaring. 

I have worked within Anthem as a medical director, albeit not one who was making those types of denial decisions, and have known wonderful doctors and nurses within that particular insurance plan, as well as in other insurance plans, whose main goal in performing case review is to ensure that patients are receiving care in keeping with best practice guidelines.  In many ways, their job is an impossible one.  It is almost impossible to uphold the fiduciary responsibility of the insurance carrier that requires that payment only be made for care that is absolutely necessary while also giving doctors free reign to practice in ways that may not be best for anyone concerned.  The normal way to meet this responsibility is by this type of regulatory approach which approves and denies payment in the sort of manner that is reported on by CBS News. 

The fact is that whenever you attempt to review cases from afar, and base determinations on either claims data or even on medical record information, you miss a big part of the story.  Even when you are able to speak with treating physicians, they may be poor at communicating the issues in a way that satisfies the black and white of insurance medical policies so that decisions are made that may not be in the best interests of either the patient, or even the insurance company. 

Recent work and recent writings have shown that medical narratives; the communications that really take place between doctors, nurses and patients are often not as cut and dry and may not fit into the nice algorithms of an evidence based medical policy.  Those narratives and the life context that clinical decisions occur in are not seen in claims data, in certification reviews, and often not even in the medical records or the quick telephone communication between a treating physician and the insurance company health professional.  Nowhere is this more true than in those who are in need of mental health treatment.  In the case of mental health care, the sickest patients can often be the most in need of an approach that is more nuanced and more in need of understanding that there may be facts that are not seen in the typical insurance review.

But there are other ways to impact care in order to decrease the care that is not necessary, protect the patient from potentially inappropriate care, and also respect the joint patient doctor decision-making process.  In my career, I have worked to build techniques that attempt to impact that decision making between a doctor and a patient in ways that do not require the type of micromanagement and approval and denial from afar that is depicted in the ‘Denied” report.  I know it can work. 

Early in my career, I was involved in starting a program that, in dealing with what looked like inappropriately long hospital stays, rather than deny payment, would deliver “Get Well” cards to people when they were admitted to the hospitals.  The cards said that we, the insurance company, hoped they would get well soon and that if all went well, based on best practice standards, we expect that they would only need to be in the hospital for 3 days (as an example).  The card went on to say that if more time in the hospital was needed, their insurance would cover the additional time so they should not worry.  This simple card decreased our length of stay average because it changed the conversation between the doctor and the patient.  It created a dynamic in which if the doctor wanted to keep the person in longer, the patient would ask why. That conversation was healthy, and moved people more towards a model of shared decision making and also fulfilled the fiduciary responsibility to hold costs to only those services which were necessary.  It used communication and positive influence rather than policing and regulation.  

It was one example of attempting to help influence people towards making their own best decisions in partnership with their doctors and nurses.  It did try to positively influence the conversations to help the joint decision making improve, but did not attempt to police the ultimate decision made. 

At Accolade, we have built a model which decreases unnecessary care, decreases admissions to the hospital, and decreases readmissions while never needing to say “no” to care.  We accomplish this even in mental health care where our data show that we increase outpatient visits, decrease hospitalizations, and lower overall costs.  We do this by using trust and positive influence, and by recognizing and addressing the impact that heightened emotions, which almost always accompany illness, have when doctors and patients attempt to make good decisions for themselves and the people they love.  We do this by forming a trust bond between that person in need and their Health Assistant and then educating him or her to the medical options available.  In this way, the right knowledge is available at the right time.  That leads to better shared decision-making.    

Our goal is always to improve the decision making but not to make the decisions for the doctor and the patient.  Our goal is to help people through the confusion of illness and not to police them and to tell them what to do.  We never want to hear anyone say, as the mother of a young woman who died from an eating disorder after being discharged from the hospital said on 60 Minutes, “the insurance company overruled the doctor.”

  

Insurance companies must maintain their duty to make sure that insurance premium dollars, whether they are paid by individuals, corporations, or government are used wisely, but that does not have to be done by second guessing difficult individual decisions made by a doctor and a patient and subsequently denying payment for the sickest patients.  There is a better way.