Docs worry as insurers’ influence grows greater
After Kim Lauerman was diagnosed with ovarian cancer, doctors wanted to give her a drug that helps prevent infections and fever during chemotherapy. Her insurer said no.
Anthem Blue Cross told Lauerman the drug wasn’t necessary. She eventually got it after an infection landed her in the hospital, but that led to another problem: She ended up missing several chemo sessions.
“The insurance has been great until I got to a point that I really needed some- thing for survival,” Lauer- man said.
Doctors say they worry about the growing influence insurers have over patient care. Some are finding that they need more approvals from insurance companies for routine things like med- ical scans or some prescrip- tions, which can postpone care for a few days or even weeks.
Insurers say advances in medical care are prompting them to review more cases before deciding on coverage. They say the checks are not meant to delay or stifle care, and they see them as a way to talk to doctors about the best approach and to guard against unnecessary treatment.
“It’s not the end of the conversation,” said Kristine Grow, a spokeswoman for the insurer trade group America’s Health Insurance Plans.
Stuck in the middle are patients who may wind up with breaks in treatment. Those interruptions can stir anxiety and, in some cases, influence the success of their care.
Lauerman worries her advanced cancer may return because her treatment was cut short. scriptions.
Doctors wanted her to get “When patients have chemotherapy and the drug chronic pain and you make Neupogen to boost infec- them go without their pain tion-fighting white blood medication for several days cells. But they had to end ... waiting for the wheels of the second round of chemo insurance companies to turn, early after she developed an it is cruel,” said the Albuinfection. querque, New Mexico-based
The 57-year-old Alpharetta, oncologist and former presGeorgia, resident also had ident of the American Medsurgery and now gets regical Association. ular scans and blood work Outside cancer care, docto check whether her cantors say coverage for routine cer has returned. tests like MRIs has become
Federal privacy laws predifficult. vent Anthem from commentAutoworker Lance Hoping on Lauerman’s case. But kins lived with neck pain spokeswoman Lori McLaughthat spread down his body lin said the insurer does for weeks earlier this year cover Neupogen. That deci- while he awaited insurance sion can depend on several approval of an MRI exam. factors including the patient’s The 55-year-old Monson, health, the treatment plan Massachusetts, resident said and guidelines from cancer his doctor needs the exam groups, she said. to find a suspected pinched
No independent research nerve, but his insurer had tracks how frequently insuronly approved less precise ance issues delay or curtail tests. care nationally, but doctors “What really stunk is my say they’ve seen a marked granddaughter had a fishing increase in difficulties over derby and I couldn’t even the last few years. hold a fishing pole to help
Dr. Ray Page says more her,” he said. “All I could than 90% of his patients need do is sit there and watch.” an insurer’s approval before Insurers base their reviews he does a positron emission and coverage decisions on tomography, or PET, scan treatment guidelines estabto try to figure out where lished by medical societies, cancer has spread. The Fort said Dr. Michael Sherman, Worth, Texas, doctor said chief medical officer for Harhis patients rarely had to vard Pilgrim, which offers wait for such approvals five employer-sponsored and years ago. individual coverage mostly
“That patient is putting in New England. their life in my hands, and They have to guard against they need to be able to trust potential problems such as me,” he said. “When you addiction to pain medicahave these outside inter- tions, radiation exposure ferences telling me I can from too many medical scans do this and I can’t do that or unscrupulous doctors ... that very quickly erodes who have their own imaging the trust.” devices and want to make
Dr. Barbara McAneny said money. They also try to rein insurer-created delays have in costs. become common in many “If we can’t do that, and we types of cancer care except see premiums continue to go for routine follow-up visits. up ... people won’t be able That includes people wait- to afford insurance, let alone ing for pain medication pre- health care,” Sherman said.