Survey reveals health plan conflicts

Pharmaceutical Representative

Results from a new survey shed new light on how frequently health plans and care providers disagree about appropriate care for patients.

Results from a survey conducted by researchers at the Kaiser Family Foundation and the Harvard School of Public Health shed new light on how frequently health plans and care providers disagree about appropriate care for patients.

The Survey of Physicians and Nurses, a national, random survey of 1,053 doctors and 768 nurses, collected quantitative information from doctors and nurses about their non-elderly patients as well as verbatim descriptions of patient experiences with health plan decisions.

"There is a great deal of inappropriate care in the health system, and it is the managed care industry that has taken on the unpopular job of controlling costs," said Drew Altman, president of the Kaiser Family Foundation. "But this level of conflict and administrative haggling between doctors and plans can't be good for our health care system or for patients who are often caught in the middle."

Almost nine out of 10 doctors said that their patients have experienced health plan denials of coverage for health services over the last two years, with denials reported most frequently for prescription drugs. Many doctors also reported that, in their judgement, health plan denials of drugs, hospital stays, diagnostic tests or referrals to specialists or mental health services resulted in adverse health consequences for their patients.

Many doctors and nurses said they are going to bat for their patients to ensure that patients receive proper care. Two-thirds of doctors said they often or sometimes intervened with plans on a patient's behalf. Often these efforts resulted in resolutions in the patient's favor, according to the surveyed doctors, with plans responding positively 42% of the time or compromising 21% of the time.

Close to one-half of doctors and nurses said they have exaggerated the severity of a patient's condition to secure coverage for medical care they felt was required by the patient. Karen Donelan, assistant professor at the Harvard School of Public Health said: "The detailed descriptions of denials of coverage provided by doctors underscore the challenges of addressing the unique needs of individual patients within the rules of managed care." PR