Health Insurer Rationing
Health insurers ration care, but they don't call it rationing, and they don't even want you to realize that it is rationing. Dr. Rich Fogoros, the About.com Guide to Heart Disease gave this its own term. He calls it "covert rationing."
When insurance companies ration care, it's a money-saving measure, in part for the greater good, but also to preserve profits or raise salaries or other reasons that their customers disdain.
Rather than dwell on the reasons that frustrate us, suffice it to know that some of their rationing does keep premiums from getting any higher than they do, and does allow insurers to stay in business.
Health insurers ration your care by limiting the doctors you may visit because they negotiate fees with those doctors. They will only pay for you to visit the ones they have negotiated the lowest fees with.
Health insurers ration care through co-pays, deductibles and caps. In fact, what they are really doing is encouraging you to self-ration. Knowing that a certain amount of your care will have to be paid from your pocket, you may choose not to get the care or drug you need.
Health insurers deny services or reimbursements for services. Denial of care is perhaps the most understood form of rationing, because it causes outrage and frustration. What most patients don't understand is that this is also the aspect of rationing that is most affected by laws and regulations, too.
In many cases, those denials may be based on science or evidence that a treatment won't work, doesn't work well enough, or is too new. For example, many patients get frustrated that insurance won't reimburse for an alternative treatment. What the insurer will tell you is that there isn't enough evidence to prove that treatment will work.
In other cases, experimental, off-label drugs or new surgical approaches are too new to show enough evidence of success, so the insurance company will not reimburse for it.
In still other cases, a doctor may recommend a treatment that is shown to only benefit a small percentage of the people who have used it (usually in very difficult medical cases), and may also be very expensive, so the insurance company will decide it's not worth the high cost for so small a probability of success.
Remember, of course, the insurer isn't denying permission for the treatment. Rather, payment for the treatment is being denied. The patient can still participate in the treatment if she can pay for it herself.