Who Should
Decide Medical Treatment: Physicians or Insurance Companies?
An important health care
issue is currently being discussed in the California Senate: who should have
control of medical treatment. “Medical
treatment” is to include diagnosis, treatment, operation, or prescription of
medicine. Although we would think physicians
are the only ones involved with deciding the treatment, actually there are many
other forces influencing the physicians' decision. In particular, Health insurance companies motivate physicians to
minimize often necessary prescriptions, referrals, hospitalization, and
tests.
Currently, in the California state
government, there are two joined bills (SB 324 and SB 557) that would stop
those who do not have a medical license from treating, or influencing the
treatment of patients. Specifically,
the bill:
“Provides that any person who makes decisions regarding the medical
necessity or appropriateness that affects diagnosis, treatment, operation, or
prescription without a medical license is guilty of misdemeanor.”[1]
Additionally, this law requires a California license
for a doctor who practices in California.
This
bill should be passed in order to minimize HMOs' and Health insurance
companies' involvement in medical treatment of patients. In this essay, I will give a background as
to the current involvement of Health insurance companies in the treatment of
patients, and my reasons for prohibiting their involvement. Then I will discuss the opposing reason and
provide my response to those reasons.
Currently,
Health Care insurers are actively involved with deciding the medical
treatment. After physicians decide upon
treatment plans, the insurance company reviews them to decide which treatment
should be authorized or denied.[2] Health plan companies tend to minimize
treatment by trying to avoid referrals, expensive prescription, hospitalization
and tests.
We
should minimize Health company involvement because Health Care is of utmost
importance to the patients, so we want the best treatment we can get --
definitely by someone who is knowledgeable and trained. However, without this bill, the treatment
doctors provide patients is strongly influenced by those who are not
knowledgeable. This is illustrated by a
recent study on doctors: “In a 1998 study ... 71% [of doctors] reported they
did not prescribe effective medications ... if ... [such prescriptions] would
require special state monitored forms.”[3] Additionally, there have been many cases
reported where HMOs altered, or even prohibited, a patient's treatment that the
physician deemed necessary[4].
Thus,
patients are often being denied of necessary treatment, and are not availed to
all the options they have because of the influence of Health Care plans. Additionally, most patients, unless they
investigate, will not know they are being denied treatment. Thus this will be beneficial because it will
provide them with the care they need and let them know about the treatment they
can receive. Additionally, since health
plans are not forcing physicians to abide by their rules, a more trusting
relation could be fostered between the patient and physician. This, I believe, is very important for the
practice of medicine.
This bill also responds to another
problem created by the involvement of health insurance: physicians are being
sued for failing to provide care when the health plans are prohibiting them
from doing so. However, if such a
malpractice suit goes through, the physicians -- not health plans -- must hold
the responsibility. This is supported
by the claim “The California association of professional liability notes that
physicians are being sued for alleged failures to provide care ... [while]
physicians are in an untenable position [to provide care] when medical judgment
is vetoed by someone without medical skill and training.” [5]
With this bill, only the physicians would have control of the treatment, so it
is proper to hold them liable.
The California Medical association,
the sponsor of the bill, has the duty to assign the medical licenses to
physicians. In support of the bill,
they claim that if those who do not have medical license are treating patients,
than the medical license loses its value.
Thus it would become less relevant whether those who treat have a
license unless we mandate the license
with this bill. [6]
This bill is, however, opposed by
groups, most of which are Health Plans or insurance companies. The main reason for opposition is that they
feel it would cause an increase in the cost of health care. As the California Hotel and Motel
Association reported [7]
this bill would lead to a 15% increase in health care costs. A major reason this bill would lead to
increase in health care cost is that the bill would eliminate initial reviews
that screen patients by nurses or allied heath professionals[8]. We should keep in mind, however, that this
bill would not stop the other health professionals from
doing their jobs[9]; it would
just stop them from doing parts of the examination that doctors should do.
Another
reason this bill would lead to increase in cost is that the process by which
treatment is reviewed would have to be changed which would mean more costs for
health insurance companies [10]. We would, however, expect that this is only
a temporary cost to change the methods for reviewing. As such, once the new methods are established, the only extra
cost is that physicians would be doing the initial reviews.
Although,
without this bill, Health insurance would probably be cheaper, patients are
often unknowingly being denied of treatment that is often very necessary. Thus the patients are still paying, yet not
getting adequate treatment. Additionally,
Health care is very important for the general population and they would not
want it to be converted into a financial issue.
Another
reason opponents, such as the California Association of Health plans, are
against this bill is that they claim it would prohibit talented doctors from
outside California to practice in California because those doctors do not have
a license for California[11]. I believe this would not be a problem
because physicians who want to practice across state lines simply have to register
for another state. Between some states,
the physicians are required to take examination, but this should not be
difficult for most doctors. It is also
important for the doctors to learn the rules of the states they are practicing
in because this would be expected of them by their coworkers and patients.
One
may expect that this bill may lead to physicians charging for excessive
treatment. However, this would not be
the case because of a commonly used system in which a group of doctors share a
“pool” of money to be used for expensive treatment. Thus, if any one doctor spends an excessive amount, he would not
be allowed to stay with his group and would have difficulties joining another
group. However, the doctors can still
spend the money for treatment that is necessary and important for the patients’
treatment.
This
bill passed in the California Senate and Assembly, but the governor vetoed it[12]. Thus its currently being reconsidered in
Senate. In conclusion, we all feel that
Health Care is important and we do not want the financial motives of Health
Care insurance companies to affect our treatment. Thus we should give the responsibility of deciding medical
treatment to those who are knowledgeable: the physicians. Health plans do have an important place in
our society providing health insurance; however, they should not interfere with
the job that physicians should be doing.
Without their involvement the medical cost would not go excessively
high, and the costs that would be there are necessary costs.
[1]Senate
Bill 557 (as of August 28, 1998) Analysis by
Senate Rules Committee, (on the web), accessed October 17, 1998;
http://www.sen.ca.gov/htbin/ca-html?GOPHER_ROOT23:[BILL.CURRENT.SB.FROM0500.SB0557]
SAFLOOR3.TXT;1/analysis/Analysis
[2]
Senate Bill 557 (as of August 28, 1998) Analysis by Senate Third Reading, (on
the web), accessed October 17,
http://www.sen.ca.gov/htbin/ca-ahtml?GOPHER_ROOT23:[BILL.CURRENT.SB.FROM0500.SB0557]
AAFLOOR3.TXT;1/analysis/Analysis
[3] Rubin, J.,
Los Angeles Times: Fight Ensues to Block Undoing of Doctor Assisted Suicide
Law, Sept. 15, 1998.
[4]
Assembly Committee on Health, Summary of Senate Bill 557 hearing on July 1,
1997 (on the web), accessed October, 17, 1998;
http://www.sen.ca.gov/htbin/ca-ahtml?GOPHER_ROOT23:
[BILL.CURRENT.SB.FROM0500.SB0557]AACHEALT.TXT;1/analysis/Analysis
[6]Senate
Bill 557 (as of August 28, 1998) Analysis by
Senate Rules Committee, (on the web), accessed October 17, 1998;
http://www.sen.ca.gov/htbin/ca-html?GOPHER_ROOT23:[BILL.CURRENT.SB.FROM0500.SB0557]
SAFLOOR3.TXT;1/analysis/Analysis
7 Assembly Committee on health, Summary of
Senate Bill 557 hearing on July 1, 1997 (on the web), accessed October, 17,
1998; http://www.sen.ca.gov/htbin/ca-ahtml?GOPHER_ROOT23:
[BILL.CURRENT.SB.FROM0500.SB0557]AACHEALT.TXT;1/analysis/Analysis
[8]
Senate Committee on Business and Professions, Summary of Senate Bill 324
hearing on April 14, 1997 (on the web), accessed October 17, 1998 http://www.sen.ca.gov/htbin/ca-ahtml?GOPHER_ROOT2:
[BILL.CURRENT.SB.FROM0300.SB0324]SACBP.TXT;1/analysis/Analysis
[9]
Senate Bill 557 (as of August 28, 1998) Analysis by Senate Rules Committee, (on the web), accessed October 17, 1998;
http://www.sen.ca.gov/htbin/ca-html?GOPHER_ROOT23:[BILL.CURRENT.SB.FROM0500.SB0557]
SAFLOOR3.TXT;1/analysis/Analysis
[10] see above
[11]
Assembly Committee on health, Summary of Senate Bill 324 hearing on July 1,
1997 (on the web) accessed October 17, 1998;
http://www.sen.ca.gov/htbin/ca-ahtml?GOPHER_ROOT2:[BILL.CURRENT .FROM0300.
SB0324]AACHEALT.TXT;1/analysis/Analysis
[12]
Bill History for Senate Bill 557. (on
the web) accesed October 17, 1998;
http://www.sen.ca.gov/leginfo/bill/current/sb/from0500/sb0557/history.txt