November 2018 Edition. Volume XVIII

In 1987 and 1988 the Health Program at RAND, Santa Monica, California published a series of articles on the appropriateness of a number of medical procedures carried out between 1979 and 1982. These reports suggested that a significant percentage of the procedures surveyed were “unnecessary.”  Even though further clinical investigation of the RAND methodology did not substantiate their conclusions this declaration served to springboard the health care system to justify the initiation of stringent utilization and peer review processes and to expend significant resources in this area. By 1992 there were 350 review firms in the United States performing utilization review on about 80% of all Americans receiving medical care.

On the other hand a 1990 survey performed by the inspector general of the U.S. Health and Human Services Department, which reviewed 500,000 cataract operations funded by Medicare, demonstrated that the United States government paid $13.3 million for utilization reviewers to save $1.4 million in possibly Utilization Review unnecessary surgical costs. These, and other data, made clear that utilization review was simply replacing medical care costs with administrative costs. On November 10, 1999 UnitedHealth Group of Minnetonka, MN (now the largest single Health Maintenance Organization in the United States) announced that it had decided to give physicians the final say in medical matters. Was this based on altruism? Not a chance, it was based on their sudden discovery of the almost decade-old observation that utilization review was economically unsound.

In keeping with the credo of “doing poorly that which need not be done at all” it is not infrequently the situation, when a real M.D. does actually engage in utilization. Unfortunately, they are frequently not qualified, on the basis of training or experience, to perform such a review.This is particularly true when a generalist performs utilization review in a specialty area.  In situations such as this patient care is often denied on the basis of being “unproven” (“experimental” or “investigational”) by the reviewer whose own coverage decisions (experience has shown)  typically reflect only non-scientific anecdotal information which they have accepted without any mechanism for further scrutiny.

Today’s “buzz” term is “evidenced based medicine”  with the assumption that real scientific data exists for every therapy; something which is blatently not true.  Actually only a small percentage of medical practice today is justified by scientific proof.  This has given the managed care community the unique opportunity to deny covering the majority of medical therapies if they so desire.  It is unusual for medicine to subject well established successful therapies to scientific study.  The energy and interest is clearly devoted to pushing the horizons of treatment.

Low back pain is a common affliction and facet blocks are often recommended as part of a conservative treatment program, and have been for over a quarter of a century.  Because this procedure, along with others, has been truly abused by some medical practitioners for the purposes of their own enrichment it has been termed “experimental” by some managed care organizations.  Rather than set criteria for use they have denied legitimate, and meaningful therapy, to many patients.  For example: there are  no evidenced based studies to show that appendectomy for appendicitis is a valid procedure.  This is true but we haven’t yet seen it being denied as “experimental.”

How to end all this foolishness and disrespectful behavior toward patients and physicians truly interested in the patient’s welfare? Actually it is simple.  Put the patient in charge of deciding what is reasonable for their own care.  How to do this?  Well, one good approach is the Health Savings Account.


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