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RX or Red Tape? : New System Designed to Cut Health Care Expenses, but Are Patients Paying Price?

August 15, 1989|BETTIJANE LEVINE | Times Staff Writer

Doris Bartlett became a widow at 4:25 a.m. on May 5, when her husband died of a massive heart attack. Complicating her grief, so she "cannot get through it or past it," is the thought that his death might have been avoided.

Robert Bartlett was scheduled to receive a pacemaker April 24 at San Gabriel Hospital. But when the cardiologist called, Barlett's insurance company wouldn't approve the $15,000 procedure over the telephone. Because his was not an emergency case, meaning Bartlett wasn't being rushed to an operating room, the doctor would have to submit a written request, the insurance company said. The letter was mailed, surgery postponed and Bartlett went home to pack his overnight bag and wait.

'Call Never Came'

"We waited two whole weeks, every day expecting to go to the hospital and get this over with. But the call never came," Mrs. Bartlett says.

The insurance company, which later said the request was "delayed in the mail room" until May 8, three days after Bartlett died, further claims he didn't need written approval in the first place.

Would Bartlett have lived if he had received the pacemaker? His cardiologist cannot be certain; an autopsy requested by Mrs. Bartlett proved inconclusive. She is left with her grief and with her questions: Who is to blame and how could such a horrible mistake happen?

The answers are complicated. And though Bartlett's situation is extreme, it graphically illustrates changes that will confront millions of Americans who get sick and try to use their health insurance to pay for surgery and hospitalization.

They will find that insurance companies no longer cover bills just because a doctor recommends surgery and patients have faithfully paid their premiums. To the growing confusion of patients and frustration of physicians, the traditional doctor-patient relationship now includes two other players: insurance companies and a new industry called utilization review.

About 200 independent utilization review firms--mostly run by financial, not medical experts--exist solely to help reduce skyrocketing medical costs. They have been so successful at the task that most insurance companies across the country now use their services to evaluate--and sometimes to challenge--

treatments prescribed by doctors for insured patients. Some firms, like Blue Cross of California, have set up their own in-house review boards.

All work essentially the same way: For non-emergency hospital procedures, insured patients must get advance authorization from the review firm to get full benefits. This is usually done by calling a toll-free 800 number, where nurses seated at computers will compare a proposed treatment with "acceptable medical practice." If the nurse is uncertain, the case will

be passed to a review firm doctor. If the procedure is deemed necessary, the firm will approve payment and dictate in advance how many hospital days will be paid for.

If the treatment is deemed unnecessary, the review firm may demand a second medical opinion and may ultimately deny payment. If a patient needs a longer hospital stay than the review firm--not the doctor--prescribes, the insurance company will not pay unless the doctor documents the need for it.

Caught in the Cross Fire

In such a complicated approval process, patients sometimes get caught in the cross fire between their doctors and the review firms--which in Bartlett's case may have proved deadly.

To avoid these hazards, experts say, consumers should be prepared to act as their own advocates, intervening on their own behalf when delays occur and seem to jeopardize their health care. They can call the 800-numbers listed on their health insurance cards or their employers' benefits departments. In some cases, a call from the insured is enough to jiggle the system into performing more efficiently.

But doctors' concerns run deeper. They bemoan the "bottom-line" mentality that permits nonmedical personnel to review their once sacrosanct decisions. Many say the review firms put them constantly on the defensive--and on the telephone--to justify their judgments.

These same doctors, however, also concede that no better way has been found to reduce wildly escalating medical costs and curtail abuses by physicians who prescribe unnecessary tests, surgeries and hospital stays.

Even Dr. Brian Gould, vice president and medical director of Blue Cross of California, expresses ambivalence. He says the review process helps reduce the "enormous waste and inefficiency in health care," and the many "unnecessary tests, surgeries and office visits" to which he says patients often are subjected: "It's not reasonable for physicians to spend millions of dollars of other people's money without having to justify the value of the services performed."

On the other hand, he says the review process "is becoming so administratively burdensome that it will collapse under its own weight. It's not particularly cost-effective to double-check on every decision that a physician makes."

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