Healthplans are dependent on guidelines and standardized medical
protocols and use these protocols to decide on payment. This
has led to both better quality care in most cases, and a total breakdown of
quality for those few people who don’t fit the protocols.
Most of these protocols are guidelines rather than
standards. A standard is a specific mandatory
rule meant to ensure consistency and quality.
It is relatively low level and
designed to always be followed. While
there are many standards in medicine, most of these are embedded in the
training and practice of every doctor, nurse, therapist and other health
professional. It is usually not
necessary to write formal medical policies for standards as most standards fit
into the “standards of care” that are part of medical licensure, overall
quality review and standard insurance contracts. A guideline, in contrast, is a recommended, non-mandatory
rule or set of rules that assist in ensuring consistency and quality and is
often more complex, nuanced, and leaves room for individual doctor/patient decision
making. Guidelines are the basis for the
overwhelming volume of healthplan medical policies and at least theoretically
should not always be followed when individual problems require more customized
approaches that do not fit the guideline.
Healthplans develop their medical policies based on scholarly
developed guidelines and expert practitioner committees, but often conveniently
forget that guidelines are non-mandatory.
Instead they administer them as standards. While they have appeals processes in place, the
appeals are often administered to test whether facts were missed that allow the
medical policy to be followed, rather than as a method to test whether the
medical policy, i.e. the guideline, should not be followed due to the unique
aspects of the situation. This is wrong
from a patient care perspective, and is a subversion of the meaning of a
guideline.
I see this far too often in my work, and even in problems
that family and friends have in their journeys through the healthplan and health
care systems. Recently this challenge of
healthplan guidelines being administered as standards affected someone very close
to me who has a rare type of seizure disorder. Let’s call him “Al” for privacy’s
sake. Al has been on a relatively new anti-seizure
medication for more than a year. This
seizure disorder was hard to initially diagnose and then hard to treat due to
the very unusual type of epilepsy. At the time, more than a year ago, I undertook
a national search to find the best epilepsy expert to diagnose and treat the
disorder. I found someone who was the leader of an international epilepsy
program, who published a massive number of studies, had numerous grants, had
been an author of books about epilepsy and who had trained many of the leaders
in the field worldwide. Al is now under his care. The
drug was approved for payment by the healthplan a year ago and if it had not
been approved would have cost over $700 per month, more than Al can
afford.
Now, more than a year later, the healthplan has decided to
deny further payment for the medication.
The medical policy requires that this drug only be used as a second drug
in addition to another first line drug.
By that logic, Al would need to be on another drug before this
particular medication could be paid for.
Thus it could be approved but only by prescribing another drug in
addition to the present drug at more cost and more risk to Al and more cost to
the plan.
When the denial was communicated via mail, Al first asked
himself, “What did I do wrong?” If is
amazing that for many people, the first instinct is to feel guilt and anxiety
over the denial when anger may be the more appropriate emotion. Al did nothing wrong and has followed
healthplan rules and physician’s instructions at every step of the
process. He has just had the misfortune
of having a disease which does not neatly fit into the medical guideline and
the policy on which the payment decision is based. If the guideline were being used correctly,
as a non-mandatory rule that acts as a quality guide, the judgment and
knowledge of the treating physician, who in Al’s case is a national expert in
epilepsy, would be allowed to override the policy. Unfortunately, healthplans all too often do
not work that way.
At any point in their life, a person may fit into the category
of someone who is benefiting from the protocols or fit into the category of
someone who is being hurt by the adherence to a rigid protocol. It is not the case that only certain people will
be hurt by the misapplication of a guideline.
Rather any of us may be affected by the type of low probability high consequence
event or illness that doesn't fit existing guidelines and the resulting healthplan
policies. At that point, people should
not be afraid to reach out and get help in reminding the paying organizations that
the medical policy is a guideline and not a standard and that rigid adherence
to the policy is neither responsible nor even safe for people when they are in
the throes of that unusual illness or circumstance.
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