Insurer denied needed medical tests, Senate finds

Insurer denied needed medical tests, Senate finds
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16

“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”

“Alright, let me put you back on hold,” came the reply.

Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.

A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.

The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.

According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”

“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
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Michael Fields was one of those found to have been wrongly denied.

Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds

The next day Fields had an emergency quadruple heart bypass.

“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”

When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.

Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.

Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.

Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.

In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.

MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.

According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.

Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
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Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.

In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.

“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”

Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.

In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.

MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."

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Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)

Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.

“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”

He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”

The "death panels" are already here

Is our current system "downright evil"?

The "death panels" are already here

Sorry, Sarah Palin -- rationing of care? Private companies are already doing it, with sometimes fatal results
Salon.com
By Mike Madden
Aug. 11, 2009

The future of healthcare in America, according to Sarah Palin, might look something like this: A sick 17-year-old girl needs a liver transplant. Doctors find an available organ, and they're ready to operate, but the bureaucracy -- or as Palin would put it, the "death panel" -- steps in and says it won't pay for the surgery. Despite protests from the girl's family and her doctors, the heartless hacks hold their ground for a critical 10 days. Eventually, under massive public pressure, they relent -- but the patient dies before the operation can proceed.

It certainly sounds scary enough to make you want to go show up at a town hall meeting and yell about how misguided President Obama's healthcare reform plans are. Except that's not the future of healthcare -- it's the present. Long before anyone started talking about government "death panels" or warning that Obama would have the government ration care, 17-year-old Nataline Sarkisyan, a leukemia patient from Glendale, Calif., died in December 2007, after her parents battled their insurance company, Cigna, over the surgery. Cigna initially refused to pay for it because the company's analysis showed Sarkisyan was already too sick from her leukemia; the liver transplant wouldn't have saved her life.

That kind of utilitarian rationing, of course, is exactly what Palin and other opponents of the healthcare reform proposals pending before Congress say they want to protect the country from. "Such a system is downright evil," Palin wrote, in the same message posted on Facebook where she raised the "death panel" specter. "Health care by definition involves life and death decisions."

Coverage of Palin's remarks, and former House Speaker Newt Gingrich's defense of them, over the weekend did point out that the idea that the reform plans would encourage government-sponsored euthanasia is one of a handful of deliberate falsehoods being peddled by opponents of the legislation. But the idea that only if reform passes would the government start setting up rationing and interfering with care goes beyond just the bogus euthanasia claim.

Opponents of reform often seem to skip right past any problems with the current system -- but it's rife with them. A study by the American Medical Association found the biggest insurance companies in the country denied between 2 and 5 percent of claims put in by doctors last year (though the AMA noted that not all the denials were improper). There is no national database of insurance claim denials, though, because private insurance companies aren't required to disclose such stats. Meanwhile, a House Energy and Commerce Committee report in June found that just three insurance companies kicked at least 20,000 people off their rolls between 2003 and 2007 for such reasons as typos on their application paperwork, a preexisting condition or a family member's medical history. People who buy insurance under individual policies, about 6 percent of adults, may be especially vulnerable, but the 63 percent of adults covered by employer-provided insurance aren't immune to difficulty...