OPINION
It is important that a trained physician can better understand the clinical context of the request than a non-physician can with a guideline alone . Having medical doctors at the apex of the coverage decision tree is more likely to result in clinically appropriate and humanistically considered determinations of financial coverage . Medical directors in insurance companies must have at least five years of clinical practice experience and be able to be credentialed with the same requirements as physicians in that insurance company ’ s network . Some health plans ( e . g . WellCare ) require medical directors to continue some form of clinical practice .
What is the role of the insurance company employed physician in the medical ecosphere ? There is both a public health role in population health , and a fiduciary role in slowing the rate of health care cost inflation . Unlike the doctor who gets to know the individual patient well during the course of medical care , the medical director for an insurance company gets to understand the characteristics of the population covered by that physician ’ s employer . There can be something elegant about the high-level understanding of a population or even of health care providers . Having access to statistical tools , the medical director can see prevalent diagnoses laid out over a map of the area . In some areas , there are more people with diabetes and in other areas a greater likelihood of cancer ; and in a third area more women with post-partum depression . Just as doctors in an examining room can pick up the signs and symptoms to help the individual patient , the medical director in a health plan can use the data available to him or her to make recommendations for actions to address those conditions at a population level . This could be by establishing disease management programs , an enhanced number of community care coordinators or increased contacts with social agencies in that sector . The senior physician in an insurance company frequently partners with existing public or private resources such as the American Heart Association , patient advocacy groups or the local health department . Of course , the insurance company doctor cannot act in isolation , but will be flanked by the non-clinical staff who have their own areas of expertise . But it is the physician in the insurance company who advocates appropriate care and who understands medical needs .
The cost of health care services began rising dramatically following the passage of legislation enabling the development of Medicare and Medicaid benefits . More people with more benefits resulted in demand-side medical inflation . Employers responded to unanticipated higher medical costs by seeking those insurers who could mitigate the cost escalation through contracting , claims payment and utilization review . There was a perceived need for doctors to provide the oversight of such reviews since as physicians they have the clinical understanding of medical practice . Physicians are better able to apply clinical guidelines developed by professional organizations with the goal of a consistent and fair determination of review of requested medical or surgical services .
Ethical practice is key to the medical profession — regardless of employment status . The physician has a professional imperative to place the patient first in consideration of the patient ’ s needs and preferences . Medical ethics also considers the physician ’ s role as steward of resources . Doctors often make medical recommendations based not only upon the physical and emotional needs of the patient but also taking into consideration the economic burden medical decisions can make . The doctor employed by an insurance company , as much as doctors employed by any organization , need to make the ethical determinations in performing utilization reviews upon the impacts to the patient / member as the first tenet ; but be cognizant in the aggregate of the impact upon a population . Employers and governmental agencies base benefit decisions upon the population-based cost of care . As an example , the GLP-1 Agonists have a great metabolic impact improving the health significantly for patients with diabetes and obesity and also for obese patients with cardiac or renal disease . But at a cost of $ 1,000 a month or more , many employers and government payers are struggling with decisions to pay that price for the health of the people they cover . In a global economy the decisions of these benefit managers have significant impacts on the viability of companies . For government , the determinations have to be made as to what other services will need to have reduced funding . By the same token , doctors employed by insurance companies face the ethical decisions of what is right for one patient while understanding the impacts to the coverages for the population . Doctors employed by other entities also face these ethical conundrums . 3 , 4 , 5
Bottom line , doctors in insurance companies are held to credentialling standards similar to doctors in direct patient care , but consider their patients to be the covered population . They represent one part of the continuum of spectrum within the House of Medicine .
References
1
Fields R , “ How Often Do Insurance Companies Say No to Patients ? No one knows ”, ProPublica , June 28 , 2023 published on line : How Often Do Health Insurers Deny Patients ’ Claims ? No One Knows . — ProPublica ( last accessed Nov 25 , 2024
2
Experian Health , “ Denied ! 2024 State of Claims : Healthcare ’ s Dissatisfaction with Payer Reimbursements Continues .” Experian Health , 720 Cool Springs Blvd ., Suite 200 , Franklin , TN 37067 ; https :// www . experian . com / content / dam / noindex / na / us / healthcare / state-of-claims-2024 . pdf
3
DeCamp M , Pomerantz D , Cotts K , Dzeng E , Farber N , Lehmann L , Reynolds PP , Sulmasy LS , Tilburt J . Ethical Issues in the Design and Implementation of Population Health Programs . J Gen Intern Med . 2018 Mar ; 33 ( 3 ): 370-375
4
Pellegrino ED . Interests , obligations , and justice : some notes toward an ethic of managed care . J Clin Ethics . 1995 Winter ; 6 ( 4 ): 312-7
5
Beauchamp T , Childress JF , Principles of Biomedical Ethics 8th Edition , Oxford University Press , 2019
Dr . James is an internist / pediatrician .
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