Relationship of Physician and Insurer in Determining Access to Health Care

By Ronald L. Scott

The role of health care insurersí decisions in determining access to health care has been hotly debated, and some states, including Texas, have responded with legislation requiring independent review of a health planís decision to deny medically necessary care to a policyholder or HMO enrollee. However, little empirical evidence exists about the relationship of physician and insurer decisions in determining access to care. A recent article in the March 4, 1998 issue of JAMA sheds some interesting light on the issue. In an article titled Insurance Coverage, Physician Recommendations and Access to Emerging Treatments (Growth Hormone Therapy for Childhood Short Stature), the authors surveyed insurers, health maintenance organizations, primary care physicians, and pediatric endocrinologists to examine the process influencing access to growth hormone (GH) therapy for childhood short stature by comparing insurerís coverage policies with treatment recommendations of physicians.

The survey examined primary care physicianís referrals to endocrinologists, and endocrinologistís GH treatment recommendations. Insurers and HMOs were asked about coverage decisions for GH therapy. The authors point out that little is known about the relationship between physician recommendations and insurer policies, particularly for expensive emerging and semielective treatments such as treatments for short stature, infertility and obesity. One problem with treatment for these conditions is the lack of consensus within the medical community (and insurance industry) about optimal utilization.

GH therapy may be expensive, costing approximately $14,000 annually for a child weighing 20 kg. Treatment is considered "semielective," and is rarely needed for life-threatening situations. Although GH therapy has traditionally been used to treat classical GH deficiency (GHD), physicians sometimes prescribe GH for other conditions, such as Turner syndrome, chronic renal insufficiency (CRI), and idiopathic short stature. For each of these conditions, the study reviewed insurance coverage policies with physicianís recommendations.

In some instances, the survey found striking differences between insurance coverage and physician recommendations. Although 96% of pediatric endocrinologists recommended GH therapy for Turner syndrome, insurers would only cover 52% of the children. For CRI, 68% of physicians surveyed recommended treatment, but insurance would only cover 58% of these children. For all conditions potentially requiring GH therapy (i.e., GHD, Turner syndrome, CRI, and idiopathic short stature), the authors examined the sequential decision-making process of referral to a specialist by the primary care physician, treatment recommendations by endocrinologists, and approval or denial of coverage by the insurer. For idiopathic short stature (short children without a defined medical disorder such as the absence of GH), 66% of the primary care physicians surveyed are likely not to refer patients to an endocrinologist. Of those referred, 74% are likely not to be recommended for GH therapy. Therefore, physicians do not recommend 91% of all children with idiopathic growth syndrome for GH treatment. Insurance coverage will not pay for GH therapy for 89% of the remaining 9%. This leaves only 1% of children with idiopathic growth syndrome ultimately obtaining GH therapy. For the other categories (GHD, CRI and Turner syndrome), referral and treatment decisions exclude 22% of the group, leaving 78% to claim for insurance benefits. Insurers reject coverage for 28% of such children, leaving 56% accessing treatment due to the combination of physiciansí recommendations and insurance coverage. The authors conclude that the discord between physician recommendations and insurance coverage represents a major challenge to mechanisms of health care decision making, access, and costs.

03/11/98