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HEALTH CARE disputes
Jim Noelker/Staff photographer
Todd Kozuscek now lives with his mother, Joyce Kozuscek, at a senior apartment building in Camden. Todd, who has epilepsy, suffered from life-threatening complication after his insurance company switched his brand-name medication to a generic without telling him.
Doctors, patients speak out to protest insurers’ control
Incidents include coverage denial and a dangerous switch of medicines.
Hot Topics
By Jim DeBrosse,
Staff Writer
9:53 PM Saturday, November 21, 2009
DAYTON — When Thomas Messenger’s heart surgeon told him he was going to use a new endoscopic procedure for removing the vein in his leg for use in coronary artery bypass surgery, Messenger was all for it.
The procedure would mean a much smaller scar, a quicker recovery and a shorter, less costly hospital stay.
But in July, four months after his surgery, Messenger and his wife stumbled across an Internet posting from the New England Journal of Medicine. A recent study showed bypass patients who underwent the new procedure were more likely to have damaged vein grafts and a greater chance of complications, heart attack and death.
“I’m scared now,” the Preble County resident said. “It’s quite a shock to read that on the Internet — that you could have damaged veins in your heart.”
Doctors who back the U.S. House health care reform bill say one of its biggest benefits will be to set up committees of respected physicians who will gather comparative data on surgeries, drugs and other treatments and arrive at “best practices” for the health care industry. They argue such panels are necessary to counter the pressure from insurers who, they say, control their costs by shortening hospital stays and using cheaper alternative treatments without looking carefully at patient outcomes.
“No one is following up (on cost-cutting measures) to see what works best for the patient,” said Dr. Lawrence Mieczkowski, a Kettering physician who specializes in the treatment of high cholesterol.
Insurance companies say they have their own internal review panels of physicians who regularly update treatment guidelines based on the best published literature in the field. Their emphasis on generics and lower-cost alternatives is “needed to make sure we’re not paying for the highest cost services and drugs simply because that’s the first thing that comes to mind,” said Kelly McGivern, president of the Ohio Association of Health Plans.
Dr. Bradley Carpentier of San Francisco is so fed up with insurance company interference in patient care that he launched a physician lobbying group in May called Stop Practicing Medicine. But Carpentier believes a best-practices approach will lead to “one-size-fits-all” medicine that will intrude on the doctor-patient relationship even more than insurance company guidelines.
What doctors really need is more transparency from insurers, Carpentier said. “We want someone to stand up and say, ‘This is what your insurance will cover,’ rather than hiding and obfuscating information from us and making us jump through all these hoops to get what’s best for our patients.”
Like many doctors, Carpentier complains that insurance companies too often refuse to pay for “off-label” uses of drugs that have been proven effective for conditions different from those approved by the U.S. Food and Drug Administration.
For example, Zyban, a medication approved by the FDA only for treating depression and anxiety, also has been shown to help smokers kick their addiction.
Dr. Darrell Lynn Grace of Dayton said she recently prescribed Zyban for a patient in the early stages of emphysema to help him quit smoking and stop progression of his lung disease. However, the patient’s insurer denied coverage because the company doesn’t pay for smoking cessation aids, she said.
“If I had lied and said (the prescription) was for depression or anxiety, it would have been paid for,” she said.
Grace said some physicians routinely lie to insurers for the sake of their patients but that she refuses. “I shouldn’t have to choose between my principles and what’s best for my patients,” she said. A 2003 report published in the Annals of Internal Medicine found that one-fourth of 700 patients surveyed felt doctors should lie to insurers to get the companies to pay for tests and treatments.
Epilepsy treatment
Epilepsy patients are particularly at risk from insurance companies that insist on switching patients to lower-cost drugs, said Janine Poppa, chief executive of the Epilepsy Association of Western Ohio.
“It takes a long time for the neurologist and the patient to work together to control the seizures (with medication),” she said. “Once you gain control — and 40 percent of patients never do — it’s absolutely critical that you stay with the same medications.”
Even switching to a new manufacturer of the same drug can alter its chemistry enough to affect the patient’s control, she said.
After months of trial and error, Todd Kozuscek’s epileptic seizures were finally under control with a combination of two brand-name drugs. But when Kozuscek changed insurers, they replaced his brand-name medications with cheaper generics without telling him, he said.
Within 24 hours, he suffered a seizure severe enough to land him in the emergency room, he said. It took his physician three days to get Kozuscek back on his previous therapy.
“I don’t think any insurance company should say you have to use the generic,” the 41-year-old Camden resident said.
What’s next?
Some physicians say the way to lower health care costs and better quality of care is collaboration among doctors, hospitals and insurers rather than competition. Mieczkowski is among those physicians who think government intervention is needed to fix the health care system. “The federal government has the most clout in bringing all the stakeholders together,” he said.
But McGivern of the Ohio Association of Health Plans says real reform must begin with the way health care providers are paid. The current fee-for-service system gives doctors and hospitals an incentive for providing more services at greater cost when less may actually be better for the patient, she said.
“Payment reform means paying providers for the outcomes of their services to patients,” she said. “Those discussions already are taking place at the state level” among state officials, health care providers and insurers appointed by Gov. Ted Strickland to the Ohio Health Care Coverage and Quality Council, she said.
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7:39 AM, 11/25/2009
9:50 AM, 11/22/2009
9:46 AM, 11/22/2009
9:44 AM, 11/22/2009
FEDERAL GOVERNMNT OUT OF HEALTH CARE.
Big brother is already taking over our lives and it sucks.
katydid71
8:26 AM, 11/22/2009