Having been at this for a few years now, I have found some disagreement about what an insurance company is doing when it performs “Utilization Management”. Physicians (many of them, not all; I’ve had at least one discussion during the course of my work with a physician who “welcomed my call, and was happy to discuss how they were taking care of this patient or any other”) will tell you that we are “dictating care”. That we are telling them how to do their work. While there’s something to that, they ignore the other side of the coin; the guidelines we use are required to be based on the best (or at least “good”) available science. Their practice, interestingly, is not.

Let’s take medications as a handy example. My employer has a guideline for statins, the most commonly used cholesterol lowering agents. It basically requires you to use the cheapest one first, and more expensive ones in a rough ascending order of effectiveness. (For the wonks, it’s simvastatin (cheap and fairly potent) followed by anything other than atorvastatin and rosuvastatin, followed by atorvastatin, followed by rosuvastatin). The reason for this stepwise use is simple: cost. Simvastatin and [anything lower than atorvastatin/rosuvastatin] are all (relatively) cheap. Atorvastatin just came off patent, so it’s a bit more expensive. Rosuvastatin is still on patent, so it’s stupidly expensive (relatively; we won’t discuss the hepatitis C drugs here).

“But”, you say, “Why not just go straight to the most potent drug?” Well, because the most potent drug is rosuvastatin (expensive), and most people will get good results on one of the less potent (and also cheaper) drugs. The next most potent is a tie between simvastatin (cheap) and atorvastatin (not as cheap, but less expensive than rosuvastatin). Most people, in fact, will do well on simvastatin, which is among the cheapest statins because it’s been around the longest. So the science says that the most cost-effective way (for the system; the individual patient sees none of this because they are mostly shielded from cost) to practice is to try simvastatin first, and then to ascend the ladder until you either get the result you need, or you get to rosuvastatin. If that doesn’t work, you need a second drug. And by the way, I should add that the bar to moving up the ladder is low. You must try a drug for 30 days. If it doesn’t work, you can move up. Since cholesterol is a long-term problem (exerting its effects over years), thirty days is a blip on the heart disease radar (3-6 months is a similar blip; it is a rare patient who gets *no* effect from any statin, even if they don’t get as much effect as is required). (Also: we do not check to see whether your doctor has checked you cholesterol in the interim; if you have a claim in our system for simvastatin, or your doctor merely *says* you’ve tried simvastatin, you can move to the next drug in line).

There is no incentive on the part of physicians to practice this way. I’ve had conversations where I have been told “I just know this patient needs Crestor (the brand name for rosuvastatin)”. Really? How do you know that? Because even were you to sequence the person’s genome, we simply don’t know enough (yet) about cholesterol to be able to say with any confidence “This person needs this drug, because we know from their genetic code that this other drug won’t work”. (Yet. People are working in this; I spoke with one the other day). The fact is you don’t know; putting someone on Crestor avoid all the work of deciding to try the cheap stuff first. “There; I put him on the biggest gun there is. If that doesn’t work, it’s not my fault”. It also adds to the ongoing, and always rising, cost of medical care. If frontline doctors don’t think about cost (and in general, they don’t), someone else must. I am that someone.

Physicians call me from time to time and say “I am just advocating on behalf of the patient”. That’s fine; that even admirable. That’s what they should be doing. I, at the same time, am advocating on behalf of everyone else who gives us money and requests that we pay for their health care also. If I give it all to you, or your patient, I will have none left for the next guy. Someone has to watch the dollars if treating physicians won’t. I say this to treating physicians everywhere: be happy that you have a doctor at the insurance company to help the company make these decisions. If it were up to the accountants, the rules would be a lot more restrictive, and exceptions would be unavailable. At least now if you think you need something, all you need to do is call (or write) and explain why this is. I am here, and I am listening. And I’m not hard to convince; you have to give me either science for why your way is better (and science moves quickly; sometimes there actually is science which I/we haven’t seen yet) or a patient factor I don’t know about which says why the guideline doesn’t or shouldn’t apply in this instance. For drugs this usually means the patient has to have tried the drug, or there are good, solid reasons to believe they will react poorly to the class of drugs it is in, and that is why you want to move up or over a class without trying all of the representatives of the class (this is true of allergies, for instance. If you’re allergic to simvastatin and want (say) ezitimibe (Zetia, a different class of cholesterol lowering drugs), I can waive the requirement that you have to try more than one statin first – but you have to try at least one statin, in order to show that you’re allergic. (And actually, it doesn’t need me; a pharmacist can waive it; we have a staff of them making these decisions about drugs at the front line of UM). And allergies are often transitive across an entire class of drugs. I see requests periodically for rosuvastatin stating that the patient has to have that drug because the patient is “allergic to statins”. Well, guess what? As is implied by the name, rosuvastatin is…a statin. So if they’re allergic to “all statins”, they’re likely allergic to rosuvastatin too! So no [ding!], that is not the correct answer, thankyouforplaying).

So essentially, the way I see my role is as a steward of other people’s money. My job is to do my best to ensure that 1) our members get the best possible care, at 2) the most reasonable price we can. “Best possible” is a real goal; we discuss these things at length where I work, and in general if a treatment, drug, or whatnot is more effective but also more expensive, we will cover it despite the expense. We may hedge it round with rules requiring you to try the cheaper stuff first if possible, but we will not decline to pay for something just because it costs a lot of money. It is in our interest to have you healthy if possible; healthy people in general consume less health care, and so cost us less.

More on this in a related post which will be about 15 minute visits and why physicians have only themselves to blame for the parlous state of the profession.