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Look Who's Coming Between You and Your Doctor


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Opponents of health care reform, especially those who resist moving to a single payer system like Canada’s, have often used a very powerful argument to sway public opinion. Any significant changes, they warn, to America's private insurance system would mean that the government will come between patients and their doctors by making decisions about the care Americans receive. Remember the fear and uproar stirred up over “death panels”?

But what if it's not the government that is inserting itself between you and your doctor? Since managed care appeared more than two decades ago, insurers have attempted to guide physicians' behavior regarding the treatments and medicines patients could have. Many insurers required preapproval for some services, especially the costly ones. Utilization nurses sat in cubicles dispensing health information and saying yea or nay to your physician's plans for your care.

Now insurers are even more likely to be the ones coming between patients and doctors. The Affordable Care Act has changed the rules of the game; health plans can no longer require consumers to disclose pre-existing health conditions or reject them for coverage if they have serious – and sometimes not-so-serious – conditions. That change means insurers will be paying claims for a lot of very sick people. How will they do that and still make a profit?

One answer seems to be to get newly insured patients to disclose their health conditions after they're insured. Using online forms similar to those used by some employers, several insurers are asking new customers to tell them about any health conditions they may have, the medicines they take, and personal habits like smoking and drinking.

According to the Wall Street Journal, Cigna is calling its new enrollees to ask about health conditions and their medical needs. To encourage people to fill out health information forms, Blue Cross Blue Shield of North Carolina is offering $50 gift cards as an enticement. North Shore-LIJ CareConnect Insurance Co. also calls new enrollees and for those who don't have a regular doctor, CareConnect sets up an appointment with one for you. Insurance companies are beginning to control your medical affairs before they ever receive a claim.

After all the talk about consumer choice over the last several years, narrow provider networks mean that patients really don't have much choice in picking a physician. But efforts by insurers to learn more about the health status of their members raise important concerns over how much choice patients will have over their treatments. How can patients be engaged with their care if insurers start directing their care decisions as a condition of having coverage?

Perhaps the larger question is: Do consumers/patients care about what would have been considered an invasion of medical privacy a few years back? One 28-year-old woman with a pre-existing non-malignant tumor in her pituitary gland told the Journal that she filled out the form from the North Carolina insurer and was hoping to get some useful information and resources. She figured the insurer couldn't penalize her and would find out about her claims anyway.

Maybe the insurer can't penalize her directly, but if it finds out through its surveys of enrollees that a lot of them take expensive medications or have cancers that require expensive treatments, those costs will likely be reflected in the rates that the rest of the people who've purchased a similar insurance plan will pay – not just the 28-year-old woman.

To minimize expenses, insurers may well charge customers more coinsurance and higher co-pays for selected services, which usually means the ones like diagnostic imaging and outpatient and urgent care, which patients use the most. It could also mean greater use of restricted networks of providers.

Insurers say they are collecting this health profile information to better manage the risk they face from having to insure sick people. Insurers are profit-making companies, not charitable institutions. We always knew they would find a way to cover those with pre-existing conditions and still turn a profit. We are beginning to learn how they will do it.

More Blog Posts by Trudy Lieberman

author bio

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.

Tags for this article:
Health Insurance   Medical/Hospital Practice   Patient Engagement   Health Care Access   Trudy Lieberman   Health Care Cost   Find Good Health Care   Pay for your Health Care   Make Good Treatment Decisions   Inside Healthcare  

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Cindy says
May 19, 2014 at 2:20 PM

My husband used to be on statins. They nearly killed him, destroying his kidneys, muscles and tendons (rhabdomyolysis). Finally, with my husband bent over on a cane and believing he was near his end, the doctor took him off the statins. That was about 6 months ago. My husband is better, and no longer needs the cane. But now we have BC/BS sending letters demanding to know why my husband hasn't filled his 'scripts. Plus, a Nurse Ratched-like person keeps calling and calling, demanding to come to our home to "counsel" him on the importance of taking his medications. Now what does this insurance company & their "patient care representative" know better than my husband's cardiologist? The drugs they're trying to push back on him nearly killed him. Plus, did you know that the new intake forms ask if you own guns and/or have guns in your home? My husband was asked that at his last cardiology appointment, something he hadn't been asked in his eight years of seeing that doctor. And I was asked the same question for an asthma checkup. My answer was: "What does this have to do with asthma?"