The author concludes that the outlook for chronic pain sufferers is not particularly bright, until such time that a not-for-profit single-payer system replaces the current treatment/reimbursement paradigm.
Unlike pain practitioners, health care insurers in the United States are not expected to function according to a system of medical ethics.
Rather, they are permitted to function under the business “ethic” of cost-containment and profitability.
This capitalist principle is a problem for all social services because they serve a sector of society that often cannot pay; either their jobs don’t pay enough or they are too disabled to work.
I think it’s absurd that a very necessary social service, like insurance for healthcare, should be in the hands of people who care only about the patient’s wallet, not their health.
This essay examined these self-serving strategies, which include
- failure to reimburse services and certain medications irrespective of their evidence-bases for clinical efficacy and cost-efficiency;
- “carving out” specific services from interdisciplinary treatment programs; and
- delaying and/or interrupting the provision of medically necessary treatment.
Blatant and more subtle strategies utilized by insurers to achieve these ethically questionable goals are examined. Additionally, this essay addressed some of the insurance industry’s efforts to delegitimize chronic pain and its treatment as a whole.
Recent efforts at health care reform have fallen short of ending private health insurance carriers’ stranglehold over the manner in which medicine is practiced, despite the fact that polls consistently indicate that the majority of Americans support a single-payer system.
As is true of all areas of medicine, the emphases on profitability and cost-containment of the health insurance industry adversely affects pain sufferers, with the ethical implications of the behaviors of insurance companies to be discussed in this analysi
Specifically, this article will address the impact of the health insurance industry on pain medicine, with an emphasis on how it has contributed to the perpetuation of human suffering.
Whether the insurance industry assumes a legitimate ethical position in regard to its actions and inactions that profoundly impact the quality of pain care in the United States will be discussed.
History of health insurance in the United States
Legislators preferred not-for-profit health insurance, as they wished to avoid the appearance of having sanctioned organizations that would extract monopoly profits from the health care industry
Blue Cross and Blue Shield were the dominant carriers, and by the early 1940s, not-for-profits controlled over three-quarters of the health insurance market.
However, in the 1950s, for-profit commercial insurance companies began to undercut the Blues by charging “low risk” groups lower premiums based on actuarial calculations, moving away from the notion of a “community rate”
Early HMOs tended to be not-for-profit organizations. However, between 1985 and 1999, the percentage of HMO enrollees in for-profit plans increased from 26% to 62%.
Not surprisingly, empirical investigation has indicated that the quality of patient care in investor-owned HMOs is inferior to that in not-for-profit HMOs, with enrollee satisfaction with medical care considerably higher in not-for-profit plans.
In the mid-1990s, Blue Cross plans began to convert to for-profit status in a number of states after the national Blue Cross/Blue Shield Association changed its requirement that all licensees be not-for-profit.
These conversions were seen as necessary in order to remain competitive with for-profit insurers, who were able to undercut Blue Cross.
Managed care is typically associated with HMOs and has been accused of deliberately denying necessary medical services in order to generate profits and enhance the wealth of executives and shareholders.
This is exactly what any public corporation is designed to do – they’re not in business for any other reason than to make money for their shareholders.
However, all health insurance—whether for-profit or not-for-profit—constitutes managed care, as it is insurers rather than patients and their physicians that ultimately decide which services will be covered, and thereby provided
The Insurance Industry and Pain Management
It has recently been posited that the fiduciary obligation of health insurers is not to its enrollees, but to its shareholders.
This simple fact is at the core of the profiteering that’s corrupting our healthcare. Until corporations, who have been given all the rights of biological people, are forced to provide value and reduce harm by a re-writing of their charter.
Concern with cost-containment (and, in most cases, profitability) inherent in the “business ethic” under which the health insurance industry operates trumps any sense of perceived responsibility to ameliorate enrollee suffering, including those enrollees suffering from pain.
Perhaps the most egregious manner in which the health insurance industry interferes with the provision of adequate pain management is through its refusal to reimburse clinicians for services that will potentially reduce pain and suffering
Numerous studies, meta-analyses, and systematic reviews have indicated that interdisciplinary chronic pain management constitutes the most clinically effective and cost-efficient means of treating most chronic pain conditions.
Additionally, interdisciplinary treatment programs are essentially devoid of adverse side effects and iatrogenic complications, which is untrue of treatments such as pharmacotherapy, surgery, intrathecal drug delivery systems, spinal cord stimulators, and other interventional approaches.
The paradox of insurers’ refusal to cover interdisciplinary pain management programs is that this practice steers patients toward more expensive and less effective unimodal treatments, ultimately helping neither the patient nor the insurer.
I encountered this frequently when I wanted to try an unusual non-opioid therapy, like acupuncture.
These findings are consistent with those of earlier studies associating opioid utilization with work loss.
This is like saying insulin utilization is related to work loss, blaming people’s lack of function on the medicine they take instead of the condition that requires them to take the medicine.
Why do they talk about “opioid milligrams” as a measure and attribute negative consequences to them without mentioning the pain they were prescribed for?
Of course, people taking more opioids would be more disabled because their pain is much worse than those who don’t need opioids.
third-party payers remain generally willing to cover prescription opioid analgesics, with coverage for and availability of interdisciplinary chronic pain management in the United States rapidly declining [
Schatmanquestioned the ethical implications of denying coverage of interdisciplinary pain management programs based upon a “policy” that is completely inconsistent with the evidence-basis.
Virtue ethical as well as principle-based ethical arguments were presented in order to elucidate the moral hazard presented by reliance upon an essentially arbitrary policy.
Interestingly, it has been noted that in order to legally overturn an insurance denial, beneficiaries are obligated to prove that an insurer’s decision is arbitrary and capricious, or unreasonable.
The ethical implications of denying services based upon ignorance are certainly clear, particularly when the evidence-bases are published in mainstream medical journals.
One would assume that health insurance carriers employ medical directors, and that these physicians should guide company policies through their appreciation of the published evidence bases.
Pain, and particularly maldynic chronic pain, is an “easy target” for claim denial, as it is often considered less than legitimate by insurers due to its often uncertain etiology. This appears to be particularly true in cases in which patients are traumatically injured, such as on-the-job injuries and motor vehicle collisions.
Although physicians are the traditional adjudicators of whether care is needed, they must now answer to bureaucratic entities such as health insurers prior to passing such judgment
So it’s the insurance company that determines treatment, not the doctor. If those 2 entities disagree, money trumps expertise and the insurance company prevails.
Maldynic chronic pain, due to its frequent lack of a clear etiology, is often viewed by the health insurance industry as illegitimate. As certain forms of suffering lack clear cut definitions, it is assumed that the suffering of chronic pain victims is not suffering at all.
Within the field of pain medicine, much of the criticism of the health insurance industry has been targeted at managed care.
these companies tend to perceive pain as a financial perturbation and inadequately treat it in the cheapest possible manner, i.e., with medications—irrespective of the iatrogenic complications associated with their use.
Because of this alleged cost-saving practice of third-party payers, chronic pain patients are often treated by disconnected health care professionals operating out of different facilities and communicating with each other minimally, thereby precluding the possibility of evidence-based coordinated care.
As mentioned earlier in this analysis, it is important to recognize that all health insurance constitutes “managed care,” as it is the insurer rather than the patient and physician that decides which treatments can be provided
Rather than focusing on patient well-being, the aim of every health insurance carrier, whether for-profit or not-for-profit, is cost-containment.
In a for-profit organization, the insurer’s fiduciary obligation is not to the pain patient who needs coverage of services in order to maintain hope of amelioration of his/her suffering, but to the shareholders who desire to see their investment dollars grow
Equally distressing, perhaps, are not-for-profit third-party payers, such as state-funded workers compensation systems. Routinely, this type of agency will acknowledge that its fiduciary obligation is not to the injured worker, but to the taxpayers of the state.
Limiting chronic pain treatment, particularly when doing so completely contradicts the abundant evidence-basis, is not necessarily unethical—particularly when insurers operate under the “business ethic” of cost-containment and profitability and do not see themselves as subject to the commonly cited principles of medical ethics
The notion that health insurance carriers do not likely consider themselves unethical certainly supports the mutual exclusivity of business “ethics” and the standard of ethics governing social justice in health care.
Third-party payers limit chronic pain treatment in other ways in the name of cost-containment. For example, insurance coverage for specialists is an issue affecting the availability and therefore the overall quality of pain care, as insurance coverage impacts the decision of whether to refer a patient to a pain specialist
Another strategy through which health insurance carriers pursue cost-containment and profitability is by delaying necessary pain management services, with these efforts having potentially catastrophic consequences.
In discussing the consequences of delay of appropriate, comprehensive treatment, Gallagher and Myers note that this practice not only increases the likelihood of acute pain developing into long-term disability and its psychosocial sequelae, but increases unnecessary costs to society through additional compensation payments and medical expenses
One mechanism through which insurers effectively delay necessary pain treatment is the requirement of preauthorization
Predictably, patients in states requiring preauthorization had significantly higher overall total direct pain treatment costs than those patients in states not requiring preauthorization.
Similar to requiring preauthorization as a mechanism for delaying pain treatment is health insurance carriers’ practice of routinely interrupting treatment once it has been initiated.
Even if prior authorization is obtained, third-party payers often preauthorize insufficient amounts of treatment, requiring providers to seek more sessions.
Another strategy commonly used by insurers to delay or terminate necessary pain treatment is ordering an independent medical examination (IME).
Most likely to be utilized in situations in which pain sufferers have been traumatically injured, numerous authors have questioned whether IME’s are particularly “independent.”
Schofferman observes that the remuneration received for performing IMEs is far greater than the reimbursement for office-based patient care, and that IME physicians logically desire to be hired for more of such work.
When IME physicians render opinions contrary to the best interests of the insurance companies that pay them, the likelihood that they will be rehired diminishes
Whether the bias demonstrated by IME providers is consciously or unconsciously motivated is difficult to ascertain, and probably immaterial. What is relevant is the suffering that the IME process can cause the patient.
However, third-party payers often order IMEs for the purpose of discontinuing treatment, with the bias inherent in the process potentially resulting in discontinuation of necessary pain care.
Benner describes the process as being “… in opposition to standards of ethical medical practice”.
Variance among health insurers in their willingness to pay for prescription pain medication has existed for many years, with Health Maintenance Organizations (HMOs) cited as “restrictive” in this area of coverage
Anecdotal reports and drug industry data, for example, note frequent denial of coverage for pregabalin for neuropathic pain, with coverage of the less expensive generic anti-convulsant gabapentin provided
two studies of patients with post-herpetic neuralgia have determined that
- initiation of therapy with gabapentin led to an increase in use of opioid analgesics, while
- initiation of pregabalin resulted in reduced opioid consumption.
Insurance companies often claim that medications such as pregabalin and duloxetine are not “medically necessary,” and will suggest alternative medications that are available in generic formulations. A frequently recommended class of alternative medications is tricyclic antidepressants, which indeed have empirically-established efficacy data supporting their use.
However, clinical efficacy in and by itself is insufficient, as the tolerability and safety profiles of tricyclics preclude their utilization in many instances
In comparative studies and reviews, the frequency of adverse events associated with tricyclic use vs the use of pregabalin and duloxetin is significantly higher, although these data are apparently not of primary concern to third-party payers.
insurers may look at this process very differently, as failure to cover expensive, evidence-based treatments may result in some chronic pain patients choosing not to reenroll—thereby resulting in potential future savings for the carrier.
Given insurance carriers’ sense that they lack a fiduciary obligation to their enrollees, it is not surprising that patient safety is not a priority for them.
Merskey and Teasell have elucidated another potential way in which the insurance industry can have a deleterious effect on pain treatment, stating that
“the view of pain may be diminished and minimized by members of the medical profession, sometimes directly because they have worked for insurance companies or provided opinions for insurance companies who seek such minimization of the suffering of their clients, our patients, and that such minimization of pain will extend not only to patients who have financial claims to make but inevitably to others who are being treated for pain by the same physicians”
The authors indicate that much of the research and clinical practice guidelines published on chronic pain is done so by scientists beholden to insurers (either public or private), and accordingly are at risk for pro-insurance bias.
It is also important to consider the ethical implications of the same physician both treating pain and rating disability for insurance purposes in the same patient. Sullivan and Loeser examined this common practice and concluded that doing so is ethically suspect. Others have expressed agreement regarding the potential pitfalls associated with both treating and rating pain and disability.
A related way in which insurers cause harm to chronic pain sufferers is through manipulation of medical (and public) opinions regarding certain pain conditions.
…despite compelling evidence of the organic causation of fibromyalgia,insurers exert an impact on acceptance of the legitimacy, and therefore treatment, of fibromyalgia by hiring physicians to write articles questioning the validity of the disorder—irrespective of the evidence-basis.
Summary and Conclusions
There is little doubt that the health insurance industry has developed numerous strategies for limiting the scope and the quality of care that chronic pain patients receive, with these strategies serving to perpetuate suffering in what is already a very vulnerable population.
…allowing an individual to remain in pain and to needlessly suffer when options for remedying or reducing these experiences has been described by Somerville as a “serious breach of fundamental human rights”
It is quite evident that the health insurance industry does not recognize an obligation to help suffering patients, as the business ethic of cost-containment and profitability to which they choose to adhere has little room for aiding those in distress—particularly when they fail to recognize any fiduciary obligation to their enrollee
As the insurance community has clearly contributed to the commodification of the American health care system, it has contributed to the degree that chronic pain patients have become what Pellegrino has referred to as “fungible.”
I didn’t know what fungible was, so I looked it up:
This is exactly where the increasing standardization of healthcare is leading us. Both doctors and patients are being treated as easily expendable and replaceable. If there are clear standards for medical care, why do we need doctors?
Pellegrino writes, “The special needs of the chronically ill … are no longer valid claims to special attention. Rather, they are the occasion for higher premiums, more deductibles, or exclusion from enrollment”
chronic pain patients have become considered little more than excessive users of health care commodities by third-party payers, thereby contributing to insurers’ lack of trust in this unfortunate population.
As a result, a climate of mutual noncooperation has developed, with this climate serving to impede patient recovery and alleviation of suffering.
Does the disconcordance of the professional ethic of pain care providers and the business ethic of the insurance industry doom chronic pain sufferers?
Like the political environment, however, the health care environment has only become more contentious over the past 2 years, with the health insurance industry certainly playing its part in fostering this contention.
For example, rather than considering measures to provide a higher level of service to enrollees, insurers have continued to increase premiums and decrease benefits, thereby increasing their profitability
Thus, until the United States moves to the type of single-payer, not-for-profit health care system enjoyed by the vast majority of the industrialized world (i.e., an ethical system), the insurance industry’s motivations will ensure that chronic pain patients continue to needlessly suffer.