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HEALTH INSURANCE CODE NEEDED

Managed care companies are the only sector of the health care industry lacking a code of conduct. It is time for that to change (see also Health Insurance).

Recently, the American Medical Association (AMA) drafted language for a National Health Insurer Code of Conduct. The code's four key principles are: clinical autonomy, transparency, corporate integrity and patient safety and welfare. I commend the AMA for drafting this code. Unfortunately, the health insurance industry has been silent on it.

Why is this code of conduct so important? Financial incentives -- not patient welfare -- are the driving force behind insurance operations.

A survey by the Medical Society of the State of New York showed that more than 90 percent of physicians indicated they had to change a patient's treatment -- or medication -- based on restrictions from insurance companies. A survey by The Toledo Blade of members of the Ohio State Medical Association and the AMA revealed that 95 percent of respondents said insurers interfered with decisions about prescriptions, 91 percent with testing, 74 percent with referrals and 69 percent with hospitalization decisions.

Every day insurance companies challenge physicians' authority and expertise. Studies and my personal experience reinforce that. This problem is particularly acute as insurance companies and pharmacy benefit managers seek to dictate a particular medication to prescribe. Insurance formularies and other barriers to specific medications make it difficult for doctors to prescribe the medication they deem the most appropriate.

In the worst cases, unauthorized drug switching occurs. That's when a medication is switched to another drug that is supposed to be its equivalent but might have different active ingredients -- often by a pharmacist and without the doctor's knowledge. This seemingly harmless switch can be detrimental to the patient, sometimes increasing risks and decreasing care.

We doctors prescribe the medication that's best per individual patient. Although in some instances a generic alternative might work, it is not always appropriate. The patient's doctor should make that determination, not an insurance company concerned with its bottom line.

The time has come for the health insurance industry to adopt a National Health Insurer Code of Conduct. The health and welfare of every patient is at stake.

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