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Highmark oversteps: Insurers shouldn't practice medicine
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Highmark recently announced a new program to restrict use of a nuclear cardiology stress test, the best validated and most widely used non-invasive test for the evaluation of coronary artery disease, the No. 1 killer in the United States.
The declared intention of this program, which was misrepresented by Highmark as being a "minor, procedural change," is to force the market to use a less expensive, but far less well validated and substantially less available ultrasound stress test.
The rapidly escalating costs of health care require that we as a nation be prudent stewards of health care resources. For decades, the American College of Cardiology and the American Society of Nuclear Cardiology, whom I and the doctors listed below represent, have been leaders in establishing national practice standards, and have consistently supported the principle that any diagnostic test should only be performed when evidence suggests it is likely to benefit the patient through improved management and outcome.
However, any program implemented by an insurance company to restrict access to an approved diagnostic study must 1) be based upon objective national standards; 2) protect patient access to appropriately indicated tests; 3) be transparent and accountable; and 4) not interfere with a physician's decision-making authority as long as those decisions are consistent with national standards. The Highmark program fails to meet any of these basic quality benchmarks.
ACC- and ASNC-published "appropriate-use criteria" for use of nuclear cardiology tests were developed by a large panel of national cardiovascular experts, including a voting representative from Blue Cross and Blue Shield, and were based upon an independent, systematic review of all of the published peer-reviewed literature. They define clinical indications that are appropriate for use of the test, those that are inappropriate, and those that are uncertain based upon published research. These criteria are the most objective and authoritative standards for performance of nuclear cardiology studies that exist.
The Highmark program, which has been implemented by a hired radiology business manager, National Imaging Associates, does not adhere to these criteria. Instead, NIA selectively extracted bits and pieces from these and other guidelines, which it recompiled and further modified with its own subjective opinions as to when a nuclear cardiology test is indicated. In the appropriate-use criteria, there are 33 clinical scenarios rated by the national experts as being clearly appropriate indications for performance of a nuclear cardiology test. The current NIA algorithm would deny 26 of these 33 appropriate indications (79 percent).
Because of the arbitrary criteria which Highmark and NIA have implemented, patients will be, and, as we have documented, already have been, denied access to appropriately indicated nuclear cardiology tests ordered by their physicians. This violates patients' rights to the best standard of medical care.
The Highmark and NIA algorithm has been kept partially secret and leaves broad opportunity for subjectivity in denying tests. Only Highmark and NIA have the data with respect to how many requested tests are denied, the clinical indications for tests and the reason for denials. There is no independent, objective oversight and no accountability.
Highmark has indicated its intention to force market substitution of the less expensive ultrasound test for the nuclear test that physicians across the country prefer three-to-four to one. Highmark claims comparability of the two tests despite the absence of any published studies to substantiate that assertion.
While claiming it no longer forces test substitution, the Highmark/NIA criteria for denying nuclear studies are based upon Highmark/NIA's subjective opinion as to when the less expensive ultrasound test is preferable, thereby forcing test substitution. We have documented Highmark refusing a test, which they acknowledged was appropriate by national criteria, because "other tests are available."
Moreover, Highmark requires precertification of a nuclear study, which is a labor- and resource-intensive task, but does not require precertification for an ultrasound test, clearly intending to force physicians to take the path of lesser resistance.
If two different diagnostic studies are both appropriate to use in a given clinical situation according to national standards, it is the exclusive right of the physician and the patient to make the decision as to which study is performed. Insurance companies do not have the right to practice medicine and cannot be permitted to assume that right.
In its press releases, Highmark has attempted to represent its cost-cutting program as being a patient-safety initiative, citing the risk of radiation used in diagnostic imaging. This again is a misrepresentation because it does not take into account the benefit of the nuclear cardiology stress test.
A basic principle of medicine for generations has been that no diagnostic test or therapeutic intervention should be done unless the expected benefit outweighs any potential risk. Nuclear cardiology tests have been extensively validated in terms of their diagnostic and prognostic value. There are no data to quantify the risk of the low-dose radiation they emit, but experts agree it is very low. In developing the appropriate-use criteria, the national experts thoroughly examined both the indications and risks of the test in making their determination on appropriateness in each clinical circumstance.
There is a far better solution to this issue. The ACC has developed and validated a comprehensive computer program to implement the appropriate-use criteria. The program is objective, carefully adheres to the criteria, is transparent and accountable, and includes a sophisticated educational component which can help physicians improve their selection of appropriate tests.
We urge Highmark to abandon its seriously flawed program with NIA, which violates both patient and physician rights, and instead implement the superior quality ACC program.
First Published November 21, 2010 12:00 am
