Vice President Dick Cheney never had to worry that his Blue Cross/Blue Shield federal employee health insurance policy would fail to cover the cost of the $25,000 to $30,000 implantable cardioverter defibrillator (ICD) installed Saturday, along with the other expenses of his recent hospital stay. While he hasn't yet received confirmation from Blue Cross/Blue Shield that the bill will be paid, Cheney spokeswoman Juleanna Glover Weiss tells Salon that Cheney assumes his policy will cover it, simply because he's a patient whose doctors decided he needed the treatment.
But according to some healthcare watchdogs, the procedure Cheney had could be denied by many HMOs. And in a strange coincidence, the major piece of legislation moving through the Capitol's corridors right now -- a patients' bill of rights -- would make it easier for patients to demand such coverage should their insurance carriers try to block it. It passed the Senate the day before Cheney entered the hospital, but President Bush has vowed to veto it.
Several critics of managed care say that, had Cheney been an ordinary cardiac patient enrolled in an HMO, he would have had to wait or fight or both to receive the ICD that now regulates his cardiac arrhythmia. Cheney has insisted at press conferences that the implant wasn't a life-or-death matter, but merely "an insurance policy," an assertion supported by his own doctors.
"I was kind of struck with the fact that Cheney needed it, they approved it, and then he got the implant," says Dr. Linda Peeno. Once an HMO claims reviewer, Peeno now serves on the ethics committee at the University of Louisville teaching hospital and has testified before Congress about methods some HMOs use to stand between their clients and necessary medical treatment.
"This is exactly the type of technique that the HMOs would treat as not medically necessary because he could live without it," says Jamie Court, executive director of the Foundation of Taxpayer and Consumer Rights and author of "Making a Killing: HMOs and the Threat to Your Health."
And Ron Pollack, executive director of the nonprofit healthcare watchdog group Families USA, agrees, insisting that ordinary managed care clients would be encouraged to make do with a course of treatment like medication to correct the irregular heartbeat that Cheney suffers from: "You could bet that regular HMO patients are not likely to receive this procedure because it is expensive."
Even Dan Stryer, a medical officer at the Agency for Health Care Research and Quality -- an agency within the Department of Health and Human Services responsible for providing the federal government with research about treatment outcomes -- says it isn't clear whether the care Cheney received for his condition, non-acute arrhythmia, could be reasonably expected by the average HMO patient.
"There is not a solid standard on this," Stryer said. "Given Cheney's symptoms, you'd have a tough time convincing a lot of cardiologists that it was time for a defibrillator." Not every doctor would call Cheney's ICD a medical necessity, Stryer said, and that's what would be necessary for many HMOs to cover it.
Many patients do undergo the procedure, of course. "About 150,000 Americans are walking around with an ICD right now," points out Dr. Douglas Zipes, president of the American College of Cardiology, who adds that, as director of the cardiology department at Indiana University School of Medicine, he has rarely had problems with reimbursement regardless of the patients' conditions.
And Mohit Ghose, spokesman for the American Association of Health Plans, an umbrella group for over 1,000 managed care providers, claims that there are both ethical and financial incentives for providers to allow patients to receive the ICD in most cases where their doctors recommended it. "If you can keep people out of the hospital and living their normal lives, that is providing the best care for the best price," he says.
But there's enough disagreement about the medical necessity of the ICD that many cardiac patients could end up on the wrong side of the "best care/best price" equation.
Ghose acknowledges that there are standards that could prevent a cardiac arrhythmia patient from receiving an ICD. "Not everyone with a heart condition should have this kind of implant," Ghose said. He does say that the ICD is within "established parameters of care" for a "high-risk pool" of cardiac patients who could get approval relatively quickly for such a treatment from most health plans (he also says he doesn't know whether Cheney fits that category or not).
A split decision among doctors often forces patients to enter an HMO's dispute resolution system, a procedure that Ghose claimed puts the patient's health, and not profit, first.
It's this dispute resolution system that the patients' bill of rights -- the one that passed the Senate, and the dueling versions introduced in the House -- deals with. And the difference between those bills and the bill the White House supports is whether HMOs should have a role in the resolution, or an independent board should decide if a patient gets a procedure. In the House bill Bush supports, the HMO would play a major role in deciding.
Ghose says patient protection laws in 40 states insure a review of care denials within a 30 to 45 day period. According to Ghose, treatment is denied or delayed in many cases not because of cost, but because "There might be a doctor reviewing the case who thinks that there is a better course of care."
Critics of the process believe that managed care denial review procedures are frequently used to discourage patients from getting the care they need. "So much of getting care from an HMO is dependent on overcoming a hassle factor," Pollack said. Peeno recalls that the HMOs she worked under would deny initial claims for major medical equipment for patients because "maybe next year, they'd switch medical plans, and it would be the expense of another provider."
This problem is addressed by both the Patients' Bill of Rights approved by the Senate on Friday, and also by the competing legislation currently being offered by House Republicans allied with the White House. While both bills call for rapid review of denials of care by independent review boards, the bill sponsored by Republicans allows for the HMOs themselves to select who would sit on such a board, which critics claim would undermine the integrity of the review.
And sometimes the patients don't even know that a certain procedure is available. Frequently, Peeno says, HMOs manage to discourage expensive procedures early in the process. She argues that some managed care officials will set caps on how much they will reimburse doctors for patient care regardless of the severity of the conditions of individual patients.
As a consequence, doctors would lose money on patients who require greater supervision, a problem that would be compounded by referrals to specialists, like the cardiologists who recommended Cheney's procedure. Consequently, Peeno asserts, doctors might refrain from even informing a patient of an expensive treatment option unless the patient's life depended on it.
So patients who don't have independent knowledge of their range of treatment options could be missing out on the advanced medical technology that Cheney has benefited from without ever knowing it, though Pollack believes that ordinary HMO clients have begun to get wise. "People have gotten used to the fact that they have to be the squeaky wheel to get the grease," he says.
But for now, Pollack thinks that the vice president's belief that he's not getting special treatment is just a fantasy: "While everybody wishes the vice president well, you know that ordinary Americans would not be able to receive this kind of care."