N.Y. Times: does
Managed Care Deny Too Little
The New York Times has asked whether managed care doesn't
deny care often enough.
Despite the horror stories about health plans supposedly
denying needed treatment, Times reporter Michael M. Weinstein on
Feb. 28 pointed to "a problem that is precisely the opposite of
the one everybody's complaining about. That problem is
too many medical treatments rather than too few."
Approving unnecessary or questionable treatments jeopardizes
both quality of care and cost containment, Weinstein wrote.
What is the basis for the Times' claim?
A law in New York that since 1997 requires health plans to
report appeals of denials of treatments doctors have
ordered. The evidence shows that the six largest
health plans in New York State averaged 2.5 appeals per 1,000
One managed care organization that covers more than a million
New Yorkers "reported fewer than 1.5 appeals for every 1,000
In New Jersey, only 69 external appeals were requested from
among 2.5 million HMO members in 1998.
In Connecticut, only 39 patients filed external appeals of
roughly one million managed care patients.
Medicare, which makes external appeals automatic for its
beneficiaries in managed care, only rarely sees such
The evidence may well overstate the incidence of denials of
One large New York health plan "reported twice as many appeals,
about 38 per 1,000 patients, as any other plan, and about 15 times
as many appeals as the largest plans." But the numbers
exaggerate the incidence of treatment denials because nonmedical
complaints, such as complaints about premium increases, were
included in the report.
Further, that plan "overturns about 30 percent of its initial
denials, often after physicians produce better evidence" that the
recommended treatment is appropriate in the particular
To ensure that quality care is delivered in every case,
Stanford University Professor Alain Enthoven says an "urgent need
[exists] for managed care to second-guess decisions by physicians to
subject patients to needlessly risky surgery and needlessly costly
A presidential commission has said that as much as 30 percent
of health care expenditures go for treatment without scientific
Medicare patients in some parts of the country are 35 times
more likely to undergo mastectomies instead of breast-conserving
surgery, "for no apparent medical reason."
Stanford's Enthoven warns: "The country risks making a
terrible mistake if it overreacts and treats every denial as an
assault on patients. Denials are a necessary feature of a