There is no question that the cost of health care in America is skyrocketing. This fact has caught the attention of legislators, insurance companies, and now doctors. Several medical societies, which develop guidelines for treatments and best practices, are adding cost into the equation. But is this added consideration for the benefit of the patient, society, or the insurance companies?
A recent New York Times article chronicled changes in the way the American College of Cardiology, the American Heart Association, and other medical associations will now be considering cost in their clinical practice guidelines and performance standards. The cardiology societies, for example, will rate the value of treatments based on the cost per quality adjusted life-year (QALY), and discourage the use of treatments costing over $150,000/QALY.
The change has the potential for both positive and negative effects for patients. On the plus side, doctors will be encouraged to consider the financial burden their recommendations place on patients. Their guidelines will also distinguish between similarly effective treatments with vastly different costs. For example, two drugs used to treat macular degeneration (an eye disease) are similarly effective, but one costs $50/dose and the other, $2,000. Prescribing the less expensive option can reduce the copays and financial worries of their patients without affecting their treatment and prognosis.
But some experts are concerned that the new standards will make clinicians put the good of society, or insurance providers, over the good of their patients. Detractors call this tendency “rationing” and are concerned that doctors will prescribe less effective treatments to patients receiving Medicare to save money for society.
Insurance companies have performed cost analyses in the past, but doing so risks upsetting both doctors and patients. They also use the practice guidelines to decide which treatments should be covered. Until now, those guidelines had explicitly excluded value and resource use. By incorporating these considerations, the medical societies could be giving insurance companies a license to deny coverage simply because a treatment is expensive, even if it is medically necessary.
Something certainly needs to be done to bring down the cost of medical treatment in America. But whether the appropriate next step is for doctors to consider cost as well as effectiveness is a matter of debate. And the risk that insurance companies will use these new guidelines against their insured clients is real. If you have been denied coverage by your No-Fault Insurance provider, contact Christensen Law for a consultation today.