November 25, 1996 in Nation/World

Bean Counters Don’t Know Best

By The Spokesman-Review
 

The health insurance industry came face-to-face with millions of outraged customers the other day, and it blinked. Good idea.

On the surface, the question was whether women should be required to go home, bound in bandages and carrying their drainage tubes, on the same day they have a mastectomy. That’s an explosive proposition, given the traumatic nature of a breast removal plus the sudden, terrifying cancer diagnosis that precedes it.

Women already were primed to explode, after being outraged when health-insurance bean counters began insisting they leave hospitals promptly after giving birth. That uproar led politicians to pass laws guaranteeing new moms a reasonable hospital stay if they want it.

However, this is much more than a women’s issue. It is becoming commonplace, unfortunately, for consumers to fight with their health insurance companies. Insurers seem increasingly determined to avoid doing what they’re paid so lavishly to do. Namely, cover medical bills. Or, in the case of HMOs, to provide the sort of care patients think they need. This is happening for two reasons:

Medical costs have been growing far more rapidly than the sluggish growth in household earnings. Care providers, insurers, patients and bill-payers all are involved in a necessary battle over costs, profits, salaries, benefits and quality of care.

Medical technology has been developing less invasive treatments that shorten patient recovery periods. That’s good news. But new treatment methods aren’t automatically embraced. Physicians disagree about methods, and patients want no corners cut or risks taken in their own care.

So when a new outpatient method comes along, patients and physicians might choose it voluntarily but there will be trouble if health insurance companies try to force it on anyone, by deciding that the ultimate in rapid recovery is all they’ll cover in every case.

Two weeks ago, a national uproar followed news that some HMOs, in Connecticut, were demanding that mastectomies be performed on an outpatient basis. Some physicians called that dangerous. Others noted that experiments with the elimination of hospital stays for mastectomy had led to lower infection rates and high levels of patient satisfaction. The experiments were done at the prestigious Johns Hopkins Breast Center in Baltimore.

But public reaction was unequivocal: Back off, bean counters.

Sensing trouble as politicians pledged to ban “drive-by mastectomies,” the nation’s leading trade group for HMOs recommended that members not refuse inpatient care for the procedure.

Acceptable solutions to the underlying problem won’t come either from insurance actuaries or from politicians. Medical treatment decisions are too complex, and too important, to be made by insurers’ rules or acts of Congress.

The better approach is information-sharing among physicians about treatment options, followed by private decision making between physicians and their patients, based on what’s best in each situation.

But how can patients and physicians be empowered to get and provide good care - and to get it covered - without removing the needed pressure to control costs? That’s a struggle and there’s just no simple way to do it.

, DataTimes The following fields overflowed: CREDIT = John Webster/For the editorial board

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