If NOT Evidence-Based NOT Medically Necessary

I cannot tell you the times I had to deal with verdicts like “experimental” or “not medically necessary” from the carriers, especially when contemplating state-of-the-art minimally invasive procedures that do shorten surgery and recovery times, lessen morbidity and cut cost.

Their determination is usually based on what is published in the literature or so they say. Having published a considerable number of papers in peer-reviewed journals over the years, I can tell you that by the time an article makes it in the journal, it is at least 2 years if not longer after the idea even came to the authors. The more respected the journal and the longer the queue for publication. Thus the so-called “evidence” is usually stale by the time it is published and people can officially refer to it.

There is quite a backlog this way and it is absolutely not fair to force the patients to wait it out, or even medically sound. Indeed if the patient is in pain NOW, he will be seeking relief via more invasive and more irreversible procedures, hence more morbidity, more risks and more failures; and/or resort to an ever increasing amount of narcotics to placate the pain. So when that article is finally published, the patient may have developed a narcotic dependency (all too common) or chronic disability secondary to surgical complications or scarring, e.g. Failed Back Syndrome, or both.

The devices used in these minimally invasive procedures have usually gone through the FDA process prior to hit the market and these procedures usually would cost the carriers less money, so why the wait. The only plausible explanation is that the medical directors and consultants of these carriers are usually retired or just about and they have not been exposed to these procedures understandably so they resist them. Another explanation is bean-counter driven: why pay now if we can pay later with the hope that later will never come about: patient feels better, changes his mind, dies, etc.

The “medically necessary” determination is even more appalling because it is NEVER made by clinicians who actually examined the patient, listened to him/her or delved into his/her case. It is made by case managers, adjusters, so-called peer-reviewers and other bureaucrats, all located way off-site. Sometimes the surgeon and the anesthesiologist get paid, implying the procedure must have been deemed necessary, but the facility (largest bill) does not get paid, probably implying the procedure should have been performed on the street or some other similar place! No rime or reason and no accountability!

There has been a clear shift towards Alternative Medicine and an increased demand for such by the population, especially Acupuncture. The latter has been practiced primarily in China for over 5,000 years and often is used exclusively for a variety of ailments. No western-style evidence-based publications to my knowledge and yet the Chinese population is obviously doing well and still growing. Draw your own conclusions!

When I underwent acupuncture training in 2001, I could not find any carrier to pay for it so I asked patients for modest cash payments here and there. Now they are starting to pay better not because there is more evidence-based publications but because they finally realized it is CHEAPER with no side-effects or morbidity to speak of. With almost 5,000 years of non-evidence-based experience (meaning no double-blind placebo studies to speak of) with this technique, at least the health insurers are not still trying to call it experimental to avoid payment.

Whether the carriers agree or not, Medicine is an Art not just a Science, and time-honored techniques like acupuncture do prove it so. Many leaps in medicine occurred during experimental processes and to deny that is to deny progress itself. Look at Viagra for example: It was being tested for blood pressure control and…the rest is History!

 

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