PHYSICIANS IN NEW JERSEY continue to close ranks against managed-care providers and insurance companies, accusing them of increasingly interfering with patient-care decisions to cut costs.

 Organized under NJ Physicians, a year-old Trenton-based organization representing about 1,100 New Jersey doctors, the physicians voiced their complaints before Steven Goldman, the state banking and insurance commissioner, at a Health Care Leadership Summit April 14 in Hamilton.

Dr. John Ciccone, a member of NJ Physicians’ leadership council, says his group has three quarrels with insurers. One is about insurers requiring prior authorization for treatments in more cases than in the past, he says.

Second, Ciccone says insurers are in many cases also asking physicians to make “therapeutic switches” from prescribed drugs to other drugs in the same class that may not be as effective. Third, he says insurers are asking physicians more frequently to do “step-edits,” which in medical parlance refers to treating patients first with cheaper or generic drugs before moving “in steps” to more effective drugs.

All this is “purely aimed at improving the financial condition of the insurance company rather than the patient,” says Ciccone, who is a practicing cardiologist at Morristown Memorial Hospital and Saint Barnabas Medical Center.

“It has reached a point where the requests [from insurance companies] are so frequent that it sets up an adversarial relationship between the patient and the physician,” he says.

“It may be potentially more expensive for the insurance company, too,” adds Ciccone, referring to the possibility of multiple visits to a doctor’s office that a patient may need to make to meet an insurer’s requirements.

Goldman does not readily buy into the physicians’ characterizations of insurers’ requirements, but calls for greater dialogue and communication between the two camps.

“The principal difficulty is an enormous lack of communication between the physicians’ community and the insurance carriers,” Goldman says. “Oftentimes, carriers throw too broad a net when they try to address certain problems, and the dialogue or the lack of dialogue between the physicians and the carriers” becomes an impediment for change.

At the same time, Goldman says he sees no end to the “tension which clearly does exist between a desire on the part of the insurance carriers to deliver medicines efficiently and the desire on the part of the physicians to treat in the manner and with the freedom that they like.”

Goldman says insurers insist on precertification in certain cases to prevent abuse of the system by a few physicians. However, he called upon insurers to work toward a speedier process to deal with precertifications.

Walter Cherniak, a spokesman for Aetna insurance company, says his company does not resort to step-edits nor require physicians to make “therapeutic switches” of drugs. He says Aetna’s formulary, or list of drugs, changes as new drugs come onboard or others become available over the counter.

Aetna’s members are made aware of the cost of drugs under various benefit plans, says Cherniak. Co-payments required from members are the lowest for generic drugs and highest for branded drugs not covered by the company’s formulary, he says.

“We want our members to fill the prescriptions that are recommended [by the physicians],” says Cherniak, adding that many members are concerned about being able to afford the drugs. “It is your decision,” he says about whether members stick to a physician’s prescription or opt for a generic variant.

Dan Emmer, manager of public relations at Newark-based insurance company Horizon Blue Cross Blue Shield of New Jersey, says, “Horizon BCBSNJ does not apply step-edits or ‘drug switches,’ … and precertification or prior authorization are based upon the policy purchased by a member or their employer.” He says, “physicians make treatment decisions for our members,” and Horizon determines whether a treatment is covered under the member’s benefit plan.

Physicians at the meeting in Hamilton wanted Goldman to weigh in on the issue of who would take the ultimate responsibility for step-edits, precertification and therapeutic switches if they adversely impact a patient’s health or become life-threatening.

Goldman described it as a “complicated” issue, but said in general he would find it “very hard to hold a physician liable” for an insurer’s decision that affects the life, health or general well-being of a patient.

Steven Kern, a principal in the health care law firm of Kern Augustine Conroy & Schoppmann, P.C., in Bridgewater, says patients have the right to appeal an insurer’s denial of coverage and take their case all the way to the state Department of Health and Senior Services.

Kern recalls a case about five years ago of a leukemia patient in New Jersey whose insurance company initially denied coverage for a cord-blood cell transplant, which was the patient’s “only chance at recovery.”

A cord-blood match to save the patient’s life was initially found in Australia, but was unavailable by the time the insurance company relented and approved coverage, says Kern. A month or so was lost in the process, and the patient eventually died, he adds.

In such cases, Kern says managed-care companies could claim they “followed the contract and the appeals process, and that they were not negligent.”

E-mail to shankar_p@njbiz.com

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