June 24, 2008  From: GreenvilleOnLine.com

 

Don't leave decisions to insurance companies

Keep people safe by allowing doctors and patients to decide on treatment

By Dr. Marion R. McMillan

 

On June 16, Gov. Mark Sanford vetoed House Bill 3912. Two major provisions of this bill deal with the determination of medical necessity for health-care decisions and who should decide: medical doctors and patients, or insurance companies. Without this courageous veto, the health insurance companies would have succeeded in gutting and eliminating important patient protections in established South Carolina law: that the determination of medical necessity for health-care treatment decisions is the practice of medicine.

 

This is a major victory for the people of South Carolina , and on Wednesday our state legislators will decide if this veto stands. I urge our legislators to overwhelmingly uphold this important veto.

 

What's all the fuss? In order to realize the historic importance of the governor's veto, one must look beneath the surface of the proposed bill to see the hidden danger to South Carolina citizens.

 

The determination of medical necessity is the heart and soul of the practice of medicine and the stewardship of the public trust in physicians. If physicians are not allowed to determine the medical necessity of health-care decisions in consultation with patients, then what are they needed for?

 

For example, when a patient becomes ill, medical care is sought from the physician of choice. Under current South Carolina law, the physician takes a history, performs a physical examination, reviews laboratory tests and X-rays, makes a diagnosis of the condition, and in consultation with the patient makes a determination of the medical necessity of treatment and the treatment that is appropriate. The encounter is recorded in a medical record, and the physician provides a rationale for the treatment decision. The physician is licensed to practice medicine in South Carolina , and is held accountable by the patient, the legal system, and state and federal authorities for the protection of the public.

 

Under the provisions of H 3912, the existing law and its protections would be scrapped, and these life and death treatment decisions would be made by an unknown insurance company medical director or other insurance company employee. These strangers will make the decision as to what is medically necessary for you or your family, even if it goes against your wishes and the recommendations of your physician.

 

Sound crazy? You bet, but there's more. The insurance company has no responsibility or accountability to the patient, or for the consequences of the life and death decisions they make. Still worse, in the words of Gov. Sanford, "the insurance company has a direct financial conflict of interest in the review process especially in favor of denial of payment." In other words, the fox is watching the hen house, and our patients are the hens. You know the rest of the story.

 

Physicians labor against the decisions of insurance companies every day at every level of medical practice, sometimes with deadly consequences. In a recent tragic example of the human cost of interference with the practice of medicine by insurance companies, 17-year-old Nataline Sarkisyan of Glendale, Calif. , died in December 2007, 10 days after the liver transplant procedure recommended by attending physicians at UCLA Medical Center was denied by CIGNA Corporation. The company later reversed its denial of coverage in the wake of intense public outcry less than 24 hours prior to Nataline's death, but too late to give her the chance at life that her physicians tried to provide. Without Gov. Sanford's veto, this tragic story could be repeated in our state.

 

The issues at stake are the relationship and trust between patients and their physicians, de facto health care rationing without accountability, and maximization of insurance company shareholder profits at the expense of patient autonomy. The financial interests of multi-billion dollar insurance businesses are already protected as patients face spiraling coverage costs, large out of pocket deductibles, pre-existing disease exclusions, disease specific limits, and lifetime maximum limits of coverage. They do not need a blank check from the Legislature to manipulate the provision of vital health-care services at the most vulnerable periods of life. No elected official would willingly allow crucial health care decisions to be made by total strangers acting apart from the decisions made by their trusted personal physicians.

 

As a practicing physician, I celebrate Gov. Mark Sanford's veto of this dangerous legislation, and urge all citizens of South Carolina to contact their state legislators to uphold the veto. The people must be protected; the time to act is now.