Deciding upon the best course of treatment for a life-threatening disease is a journey often fraught with apprehension and uncertainty.  Because patients rarely possess the comprehensive medical knowledge necessary to evaluate all their available options, they rely upon their physician’s expertise to guide them through a decision-making process that identifies a personalized treatment plan.  A sense of trust and mutual respect between the patient and physician is critical to this process.  It is therefore important to guard against attempts to influence the physician’s treatment recommendations by those who might benefit financially, especially in the form of kickback arrangements to the physician.  Insurance and pharmaceutical companies should neither be allowed to reduce the list of widely accepted treatment options down to their preferred few nor provide financial incentives to the physician in return for selecting from their short list.  

Insurance companies tend to benefit financially when access to care is more limited and fewer treatments and procedures are offered. Through practices often referred to as “utilization review and management,” some insurers have devised creative ways either to limit access or steer treatment decisions toward a limited set of options defined through a process overseen by the insurer themselves.  

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For example, at least one major insurance company has launched a program that offers physicians an incentive of $350 per month per patient when they prescribe a cancer patient one of a few pre-determined options defined by the insurance company’s drug “pathway.”  These insurer-designed pathways do not represent the full range of viable treatment options as defined by the guidelines of nationally recognized and highly credible physician-led organizations. 

When it comes to patients with chronic, life-threatening and debilitating diseases like cancer, advocacy organizations are naturally going to err on the side of more access and more options rather than less.  We are, therefore, deeply concerned that such payer-sponsored guidelines will short circuit the decision-making process between physicians and patients by serving as a substitute for clinical judgment, and may limit patient access to viable treatment options.  At the very least, patients have a right to know when their physician is participating in an insurance company program that provides direct monetary payments in return for placing a patient on a pre-selected treatment option.  

Such programs are analogous in many respects to the type of kickbacks, inducements, and “payola” that are no longer allowed from drug makers.  Neither insurance companies nor drug manufacturers should be in the business of developing pathways or incentives designed to influence the physician’s decisions or recommendations.  Physicians should not be paid a monthly incentive to prescribe one particular drug over another when both are considered viable options according to established clinical guidelines.  If reasonable clinical evidence exists to support one drug treatment regimen over others based on what is going to provide the best approach for the patient, then physicians should be trusted to follow the evidence without an extra financial inducement to do so.  Such is their obligation and duty to the patient; a responsibility physicians take very seriously.   

Patients have the right to know the viable treatment options that exist for their diagnosis, and to have an honest consultation with their physician about the various risks, benefits, and costs associated with each. 

As part of the Physician Payments Sunshine Act passed in 2010, certain pharmaceutical and device companies are required to disclose publicly their payments to physicians and teaching hospitals in the interest of transparency.  The same approach could be taken with insurance companies trying to pressure doctors and the treatment decision-making process by making extra payments to physicians or their practices when they choose from a limited drug list defined by the insurer who in return stands to benefit financially as well.  While lawmakers have made increased transparency a priority in health policy in recent years, there is still work to be done. 

Patients need to have confidence and faith that they will not simply be steered to a limited range of treatment options pre-selected by their insurance provider.   Ultimately, the process needs to be designed so treatment protocols are optimized and personalized for each patient according to the physician’s clinical judgment.  That is, after all, what medicine is all about.

Balch is the chief executive officer of the Patient Advocate Foundation and National Patient Advocate Foundation.