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I heard that...

...a bureaucrat will be between me and my doctor now that healthcare reform has passed. Is that true?

This is not true. The Patient Protection and Affordable Care Act (PPACA) does not include government involvement in decisions between you and your doctor. However, insurance plans—both private and public—do have a say in what gets paid for. Their financial restrictions may influence care decisions.

One goal of healthcare reform is to extend healthcare coverage to Americans who do not have it.  However, when health insurance companies or public programs help pay our medical bills, they also have a say about what gets paid for.  In this way, they can come between you and your doctor.

Despite what you and your doctor think is best, health insurance plans may limit:

  • the kinds and amounts of care that are paid for without needing authorization,
  • the kinds and amounts of care that are paid for in a given situation,
  • payment for care for a pre-existing condition,
  • payment for care beyond an annual or lifetime dollar limit, and
  • care from doctors or in hospitals outside the plan’s network.

Doctors and patients may have to request permission from an insurer for a particular treatment (“prior authorization”), and the insurance plan may decide not to pay for that treatment. Or, the insurance plan could refuse to pay for treatment the patient has already received (“utilization review”) because it is viewed as having been outside the rules of the plan. For more information on how this might happen, please visit http://health.howstuffworks.com/utilization-review.htm. 

For several reasons, all insurers—public and private—limit what they will pay for.  Payers can only pay out what they collect in premiums or government payments. Claims for unnecessary care can take funds away from more valid claims.  And, unnecessary treatments do not improve health; most treatments have risks that can actually endanger health.  Healthcare experts believe that the U.S. healthcare system delivers (and pays for) a significant amount of unnecessary care (Wennberg, et al., 2008), and this is mostly ordered by physicians and received by patients.  Especially when doctors have a financial incentive to order certain kinds of care—for example, when physicians own their own imaging equipment and are therefore paid for every scan they order—insurers want to be sure that what is ordered is actually necessary.  In for-profit insurance plans, it may be more profitable to deny—and therefore not pay—some claims.  When a claim is denied, patients and doctors can appeal these decisions, but it can take time to resolve.

Many people are currently struggling with insurance plans coming between them and their doctors on healthcare decisions. For example, the California center that helps people with health insurance problems received 90,000 calls in 2007 about disputes over what an insurance company would pay for (Kaiser Health News, 2008).  Georgia physicians have to request permission from insurance companies before they deliver 880 different services (Berry, 2009), and the American Medical Association is promoting a National Insurer Code of Conduct because its members believe that insurance companies interfere with the doctor-patient relationship (Business Wire, 2009). 

Government programs that pay for healthcare also have rules about what they will and will not pay for. For example, in many states, Medicaid requires prior authorization for some kinds of prescriptions (Fisher, et al., 2004), and the Government Accountability Office (GAO) has recommended that Medicare require prior authorization for imaging scans done in doctors’ offices (Kaiser Health Policy Daily Reports, 2008). 

Even after the passage of healthcare reform, the payers for healthcare will continue to play a role in at least some decisions about patient care. Neither public nor private insurance prevents you from paying your own money for care they won't pay for but that you want anyway.

Sources

Wennberg, John E., Shannon Brownlee, Elliott S. Fischer, Jonathan S. Skinner, James N. Weinstein.  2008.  An Agenda for Change:  Improving Quality and Curbing Health Care Spending:   Opportunities for the Congress and the Obama Administration.  December.  www.dartmouthatlas.org/topics/agenda_for_change.pdf.

Kaiser Health News.  2008.  San Francisco Chronicle Examines Health Insurance Claims Denials.  June 24.  www.kaiserhealthnews.org/Daily_Reports/2008/June/24/dr000052921.aspx?referrer=search.

Berry, Emily.  2009.  Study Quantifies Prior-Authorization Burden.  American Medical News, May 20.  www.ama-assn.org/amednews/2009/05/18/bisd0520htm. 

Business Wire.  2009.  National Health Insurer Code of Conduct Hits 1000 Signatures of Support.  July 6.  http://findarticles.com/p/articles/mi_m0EIN/is_20090706/ai_n32140309/

Fisher, Michael A., Sebastian Schneeweiss, Jerry Avorn, Daniel H. Solomon.  2004.  Medicaid Prior-Authorization Programs and the Use of Cyclooxygenase-2 Inhibiters.  New England Journal of Medicine 351(21):  2187-2194.

Kaiser Health Policy Daily Reports.  2008.  GAO Recommends that Medicare Require Prior Authorization for Medical Imaging Services at Physician Offices.  July 15.  www.kaisernetwork.org/DAILY_REPORTS/rep_index.cfm?DR_ID=53300

Since 1997, The Health Foundation of Greater Cincinnati has invested over $111 million in projects that improve the health of the Cincinnati area. With major healthcare reform imminent, the Health Foundation aims to be a source for credible, timely information that can inform people in our region about the healthcare reform debate. While we do not support any specific plan or approach, we do support certain principles that we believe would improve access to healthcare and make our region healthier.

The Health Foundation supports a healthcare system that:

Please visit http://www.healthfoundation.org/reform for more information.