Although Governor Schwarzenegger's healthcare proposal failed to pass the state legislature, both the CMA and LACMA are on record in support of some form of healthcare reform. As physicians, we are painfully aware of the control that insurance companies exercise over the care we provide for our patients. We find ourselves frequently at odds over requirements for prior authorization for medications, procedures, imaging studies and even necessary laboratory tests with insurance company medical directors who may not be aware of the latest advances in a given specialty.

In my opinion, the determination of medical necessity should not be performed by an absentee physician, and denial of medical procedures, tests or therapies should never be permitted, unless the physician employed by the insurance carrier speaks directly to the physician providing care to the patient in question. This would ensure that all the facts, extenuating circumstances, and individual vagaries of a patient's medical and social needs can be appreciated by the insurance companies' designated medical director reviewing a case.

The CMA House of Delegates addressed the issue of medical necessity and considered Resolution 403-07 at its October meeting in Anaheim. The resolution reads:

Medical Necessity Definition

RESOLVED: That medically necessary care is determined by a prudent licensed physician who personally examines the patient; and be it further

RESOLVED: That failure to perform a good faith examination when determining medically necessary care constitutes unprofessional conduct; and be it further

RESOLVED: That this matter be referred for national action.
As of this time, there has been no action on this important issue by the CMA. However, through its CMA Trustees, LACMA has placed this important item on the CMA Board's agenda. You can be sure we will follow through on this resolution, which has significant implications for all of us. Recently, for example, Aetna, Humana, and WellPoint have issued policies denying the routine use of anesthesiologists during colonoscopy, even when the gastroenterologist requests a consultation. Consequently, patients are subject to a procedure that may be unpleasant, and may cause some of them to forego this important examination. The short sighted ban on use of anesthesiologists may result in significant increases in total health care costs when more patients decide to skip an unpleasant exam, and more colon cancers go undiscovered.

No insurance company should be able to unilaterally determine that the provision of anesthesia during a procedure is no longer medically necessary without involving a patient's physician on a case-by-case basis. Of course, the insurance companies object because it is simpler to issue administrative edicts than it is to carefully consider each individual's unique medical problems. While the ban on routine use of anesthesiology impacts colonoscopy today, tomorrow it may be cataract surgery or even knee arthroscopy under local with sedation where the presence of an anesthesiologist can ensure a better outcome for the patient.

What I find particularly frustrating about the control that insurance companies have is the "what would I want for myself?" test. I suspect most of the medical directors would want their colonoscopy with propofol under the supervision of an anesthesiologist. I know that when I am ready for my cataract surgery I want intravenous sedation by an anesthesiologist. Yet, I fear that by the time I am in the age group that requires more procedural interventions, I will be subject to more discomfort--all under the excuse of insurance company rules, unless I pay my own way. This is where medicine is moving: Patients will be expected to pay for what they want because their insurance companies will not.

In the long run, perhaps this is best. Insurance should be for catastrophic costs. As patients assume more direct responsibility for the cost of their care, they will be better consumers and vote for what they desire with their dollars. We already see this in plastic surgery. However, until that is national policy, patients pay for health insurance that provides a level of care that suddenly and without a change in premium or contract is no longer there--and that's not right. Let me know your thoughts and how LACMA can help you reassert physician control over the practice of medicine.