MSSNY president: Insurer settlements highlight need for code of conduct

Attorney General Andrew Cuomo's latest settlement with a major health insurance company has again shined the spotlight on a secretive practice by the health insurance industry that has seriously impacted patients and their physicians for many years.

The agreement with health insurance giant UnitedHealthCare settled accusations that its Ingenix subsidiary manipulated data to cause much higher out-of-pocket costs for patients, and significant underpayment for their treating physicians. A report issued by the attorney general indicated that the scheme "translates to at least hundreds of millions of dollars in losses for consumers over the past 10 years."

Both patients and physicians will now have transparency into how health insurers determine payment levels. However, the abusive business policies that led to this historic settlement highlight the need for comprehensive reform of the practices of this multibillion-dollar profit-generating industry.

The attorney general's settlement comes on the heels of other major settlements with the health insurance industry that revealed the extent to which some health insurance companies have profited at the expense of patients, as well as doctors who sought to provide the best clinically appropriate treatment. But these settlements have only begun to scratch the surface of insurance problems encountered by patients and their physicians.

Many believe that these problems can be addressed voluntarily by the health insurance industry on a national basis. It is for this reason that New York sponsored a resolution at the AMA Interim Meeting in Orlando, Fla., calling for a voluntary Code of Conduct for the health insurance industry.

The purpose of the code is to articulate a series of principles that a health plan would follow when they create policies that impact upon review of medically necessary care, creation of drug formularies and payment for care. Central to this initiative would be assuring greater transparency to patients and their doctors regarding how these policies are developed.

Such a code would better assure that the business decisions these companies make are not inconsistent with their oft-stated goals of assuring that patients receive the most clinically appropriate care and medication. It is anticipated that this code will be reviewed by the AMA House of Delegates in June. Hopefully it will be a bridge to a better working relationship between physicians and the health insurance carriers.

Michael Rosenberg, MD, president, Medical Society of the State of New York

Note: This item originally appeared at http://www.ama-assn.org/amednews/2009/03/09/edlt0309.htm.