Not buying it

In “The Health Insurance Shell Game,” Nortin M. Hadler and Janet Schwartz lay out some of the insanities in the way we handle health insurance in this country. But towards the end of their post, they start discussing the fact that some treatment options are less effective or ineffective, and suggest a good way to reduce health care costs would be for health insurance to refuse to cover various treatment options.

We should be offered a “high efficacy option” at lower cost than an “any efficacy option” and no one should be offered an option that indemnifies for interventions that have been studied and cannot be shown to offer a clinically meaningful benefit.

There are a few problems with this line of reasoning. First and foremost is that health insurance already refuses to cover a variety of treatments, as many patients with complex or difficult conditions know, and this has not solved the terrible excesses of health care costs.

I disagree with the notion that we can clearly delineate a large new set of treatment options which “cannot be shown to offer a clinically meaningful benefit.” Evidence-based treatment protocols can provide valuable guidance in prioritizing treatment options in the absence of further information, but many patients are not approaching their health care treatment as a blank slate. You (or your doctor) may already know that the treatment most likely to help an arbitrary individual based on statistics will not be effective for you. A study showing that a treatment is ineffective for many or most people does not establish that it cannot help some specific individuals, and we often don’t have a way to determine which individuals a treatment will help without trying it. Medical studies which insurance companies already rely on to deny coverage are hardly infallible; in fact, they are rife with fraud and conflicts of interest, and results often cannot be replicated or directly contradict other studies. When studies of well-known treatment options are repeated, the measured effectiveness appears to decline without a clear explanation. And when we study placebos, a treatment option which we know cannot have any clinically meaningful benefit, we discover that placebos can have significant clinically meaningful benefits.

But none of this matters when we are working to convince you, the beleaguered consumer, that the reason your health insurance premiums are so high is that there are lots of other people pursuing useless treatments. Those other people are spending their days at the hospital for fun, and wasting your money to do it. And when you are denied coverage for a treatment, you should be grateful because it wouldn’t have helped anyway.

If you buy this argument, I’ve got a great insurance policy to sell you.