Denying Coverage = Good?

In the heated debate before Congress passed the Affordable Care Act (“health care reform”), starting in the summer of 2009, there were persistent rumors that the bill would create “death panels” to decide whether certain patients should not be treated due to expense. While the rumor was thoroughly debunked, it did lead to Congress removing a provision that would have authorized Medicare to cover voluntary end-of-life planning consultations with a counselor. And the rumor may be one reason the law took a conservative approach toward comparative effectiveness research, examining which treatments work well and which ones don’t.


As a recent article at Kaiser Health News notes, the law established the Patient-Centered Outcomes Research Institute, or PCORI, an independent organization charged with comparing the treatments available for health conditions and issuing recommendations. Its recommendations are nonbinding, although any private insurer can base insurance coverage decisions on PCORI recommendations, and Medicare can do so but only after a drawn-out process that includes public comment. The article notes, however, that despite evidence that they offer few benefits and may even cause harm, certain procedures are still covered by Medicare and most private insurers because doctor and patient groups protested against eliminating coverage. These treatments include vertebroplasty (the injection of medical cement into spinal compression fractures) and the drug Avastin for breast cancer, whose approval for that form of cancer the FDA withdrew last year. The drug can, however, still be used “off-label” for breast cancer at the discretion of doctors.

Opponents of restricting insurance coverage based on comparative effectiveness research, including many doctors and patient advocates, note that studies are often contradictory — one might show a treatment to be useless, while another might show it to have benefits. Only after years of research, they say, and sometimes not even then, can a verdict be reached. Advocates of coverage restrictions note that doctors often make treatment decisions based on habit and the advice of colleagues rather than objective research, and that expensive, “cutting-edge” procedures may be prioritized simply because they are new. Basing coverage decisions more aggressively on research, they say, will lead to both better patient outcomes and lower health-care costs.

What do you think — what standard should be used to decide whether an insurance plan covers a medical treatment? Should the cost of a treatment play a role in that decision? Should public insurance, such as Medicare, be held to a different standard than private insurance plans? Can doctors be trusted to make treatment decisions based on research, or should insurance plans try to help guide their decisions? Leave a comment below!

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  • Dr. steve davis, Ph.D. U of Georgia

    “thoroughly debunked?” Is that because you feel the New York Times is more reputable than the Lieutenant Governor of New York? Is the New York Times ALWAYS right? For instance:

    The New York Times minimizes the role of the atomic bomb – and thus the heroism of Gen. Paul Tibbets – in his obituary today.

    Brig. Gen. Paul W. Tibbets Jr., the commander and pilot of the Enola Gay, the B-29 Superfortress that dropped the atomic bomb on Hiroshima in the final days of World War II, died yesterday at his home in Columbus, Ohio. He was 92….

    TheTimes says, “…in the final days of Work War II,” as though one had nothing to do with the other. The reason they were the final days of the war is because Tibbets flew that plane.

    Read more:

    So the A-Bomb had nothing to do with WWII ending, AND there are no Obama Death Panels, because the NY Times says so, right? The rest of the news media (e.g. Fox) and elected public officials just dont even get the time of day, I assume, in your version of truth.

  • Joe

    The decision of what treatments a patient should receive should be between the patient and their physicians. When we allow insurance companies or the government to decide which treatments are “preferred” based on non-medical criteria such as costs or whether or not the supplier has a “deal” with the payer it can lead to sub-standard care and unnecessary waste, such as when I have to throw away a perfectly good glucometer because another company made a deal with my insurer, so my current test strips are no longer covered; or when I recently had to start using a less effective form of insulin because the product my doctor prescribed was not my company’s “preferred” treatment.

    There should be only two standards: Approved as safe and effective or not approved as safe and effective. If a treatment is approved, the insurer should have to pay. No “preferences” involved.

  • Ferne

    I am so tired of the government controlling our lives. They even decide if a med that the dr. ordered comes in a dose that can be divided they won’t let you take the dose the dr. ordered. Why do we even pay for insurance if the non-medical government people think they know better. It’s going to get worse, folks, and soon we won’t get anything we need unless we are part of the government. Let us have the same medical insurance the government gets and make it fair.

  • Lori

    The claim of “Death Panels” actually HAS been thoroughly debunked for all but the completely uninformed. The Actual “Death Panels” are thoroughly entrenched- mostly in private, for-profit insurers’ plans, the ones who spread the most lies on the subject.
    If your insurance company has a “Utilization Review Board,” then you are subject to a for-profit Death Panel. Basically, if your insurer feels that treating you will cut into their profits, they will deny you treatment, no matter how much you may need it and no matter how effective it is. “Lifetime limits” also result in the unnecessary deaths of many, even small children with serious health problems.
    Since the for-profit insurers fought the hardest against the average person’s ability to afford meaningful health insurance coverage, it makes sense that they would have the most vested interest in spreading lies. Unfortunately, many people are so brainwashed that they never bother learning the truth, and often ignore the truth when it is right in front of them.
    The only currently government run “Death Panel” was initiated by the GOP Governor of Arizona. Basically, if you are on Medicaid and need transplant services, you’re out of luck. They have no problem with allowing you to die. If you are poor, you are worthless to the GOP. Therefore, there is a strong interest in allowing poor people to simply die in a GOP run state.
    Allowing people to discuss end of life care with their doctor was a benefit and not a requirement. There is ample proof that this communication with the doctor greatly improves the quality of life for people with serious illnesses and terminal illnesses. It provides comfort to the family, as well, as they know for certain what their loved ones’ decisions and wishes are and don’t have to guess. Thanks to GOP lies, this vital means of communication is not covered and the expense of it must be borne by the patient. All to fight a person’s inherent right to make choices that impact their quality of life and dignity. Why? It makes no sense, but ignorance is the order of the day on the Right.
    To still believe that “Death Panels” are anything but profit protectors for the private insurers to deny necessary coverage to individuals who have paid their premiums in good faith is willful ignorance, and something we need to remove from healthcare.