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Power Returned to Doctors

© Keri

This week, the major networks reported a startling policy change at UnitedHealth Group, one of the largest health maintenance organizations in the USA, the power to make decisions regarding the medical necessity of treatment was returned to the physician. This may only indirectly effect those of us with thyroid disease, but as a former utilization manager, I feel the need to comment.

Historically, managed care companies have strictly regulated the treatment options available to patients and physicians. The managed care companies credited this policy with the dramatic decrease in healthcare costs over the last twenty years. A request for a different treatment plan required a major investment of time and effort on the part of the physician and staff to obtain the necessary authorization. Often it was easier just to say, "your insurance company does not cover that option". Many of us have been caught on that merry-go-round.

Those of us battling with the HMO often felt their philosophy was "the cheapest care is no care at all". In fact, a UnitedHealth Group spokesman was quoted as saying that they found they were approving 99% of the requests for authorization and spending an over 100 million dollars to review those requests and deny the remaining 1%. In returning the final decision to the physician, they hope to reduce administrative costs. It might appear that this decision like others in the past is actually profit driven.

Other HMOs are expected to follow and many have already decreased the number of procedures that require prior authorization. The question now is how will this impact the cost of healthcare. Will premiums rise as doctors prescribe more expensive forms of treatment? UnitedHealth does not expect premiums to rise, but some lobbyists are predicting a major increase.

Is it possible that a doctor and patient can work together to determine the best and most cost-effective treatment? Perhaps returning power to the lower levels may improve the outcomes and eliminate recurrent office visits and potential complications. Often in managed care, the physician had to begin with the least expensive type of treatment and work up to a more expensive, but perhaps more effective one. More efficient use of diagnostic testing and treatment options could reduce cost.

It is interesting to note that UnitedHealth still expects doctors to justify surgery and expensive forms of treatment. The plan will now focus on long term practice patterns rather than reviewing doctors on a case by case basis. However, those doctors shown to be practicing wasteful medicine will still be dropped by the health plan. Who will define "wasteful medicine"?

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