Hello Richard - Thank you for this very thoughtfu...

2009-10-31T10:19:17.039-04:00

Hello Richard -

Thank you for this very thoughtful comment and for sharing your experience in medical management.

You have the makings of a valuable article or op ed piece here - a typology of insurer "villainy" and "pseudo-villainy." Your description of "process villainy" is especially useful. I vaguely recall a Sounding Board article from the New England Journal, probably in the 1990s, discussing "process villainy" as a technique used by some managed care companies to control costs via the "hassle factor." I know there is widespread suspicion about "process villainy." Insofar as it is done deliberately it's incurs a high cost with regard to trust from consumers and providers. Ineptitude is bad, but more forgivable, especially when it is acknowledged, apologized for, and fixed.

I think we'd agree that demonizing insurers when they set limits that are based on evidence and done in an open manner is "pseudo villainy." In discussing the ethics of limits I often invoke the image of Mother Theresa as CEO to make the point that setting the right kind of limits is an ethical responsibility, not a moral crime.

I appreciate your comment - I hope you "visit" again!

Best

Jim

As a healthcare system physician executive and a f...

2009-10-29T16:21:14.359-04:00

As a healthcare system physician executive and a former Medicare Advantage Plan medical director, I offer the following thoughts and observations.
1. Villainy amongst health insurers takes many forms. First, there are the obvious cases ("big fish stories" in the media) about denials of life saving treatments that should have been covered. When a line is crossed in that a arguably medically necessary case or borderline case is denied and the results are death, then this is outright villainy. These cases are porbably few on a percentage basis, but I do not believe penalties reflect the severity of the consequences.
2. "Process villainy" is something that many providers and consumers suspect, which I arbitrarily define as the DELIBERATE use of convoluted, complicated processes and delays to discourage the payment of claims, resulting in clinical or financial harm to many thousands of beneficiaries.
A real problem is that there is very little literature to quantify this problem or accurately reflect its impact.
Many ethical insurers do exist, and I was associated with one. But other executives within our organization relayed stories of working at other commercial plans and the callousness of decision making.
3. I wholeheartedly agree that cost and medical necessity are realities, and that coverage decisions are not inherently evil.
Whether the left or the right attempt to scapegoat greedy insurers, pharmaceutical companies, or faceless bureaucrats, the problems remains of how to allocate expensive care to many in a manner that does not bankrupt the US economy and rewards quality more than merely volume

Comments on Health Care Organizational Ethics: Are Health Insurers Villains?

Hello Richard - Thank you for this very thoughtfu...

As a healthcare system physician executive and a f...