MICHAEL M. GRAHAM, MD, PHD
Michael M. Graham, MD, PhD, warned of a "healthcare crisis in the making" caused by a growing trend by health insurance companies and the Centers for Medicare and Medicaid Services to refuse coverage for life-saving molecular imaging tests for patients with cancer.
"Cancer patients who are fighting for their lives are growing angry over the arbitrariness or perceived greed of insurance companies or CMS in not approving payment of a test ordered by a physician," Dr. Graham said at the 2010 SNM meeting in Salt Lake City. "We are concerned that denying coverage for imaging is becoming more of the rule, instead of the exception."
He noted that PET/CT, SPECT/CT, and other hybrid imaging scans have been proven to catch cancer, heart, and brain diseases early on, allowing for precise targeting and therapy and saving unnecessary expenses like surgeries or extended hospital stays. He argued that this not only benefits the patient, but actually saves the healthcare system money in the long run.
Dr. Graham said that overly restrictive authorization criteria and the lack of expertise by administrative decision makers at health insurance companies are putting thousands of Americans at risk each year. Insurers must defer issues of medical necessity to physicians on the front lines who know the particulars of their patients' cases better than anyone else and who are much more familiar with the medical literature to determine which tests are medically necessary and which are not, he said.
"No doctor wants to be second-guessed by an administrator thousands of miles away with little or no understanding of the nuances of a patient's unique situation," Dr. Graham pointed out. "We cannot let professional payers preempt the opinions of professional molecular imaging practitioners. Denying reimbursement for imaging removes one of the most important weapons in a physician's arsenal to fight serious disease."
SNM is particularly concerned about the "rising power amassed over the last decade by radiology benefits managers (RBMs)," he explained. According to a study by the Government Accountability Office, about one in 10 patients insured by a commercial health insurance company in 2005 had to get prior authorization through an RBM before receiving an imaging test. Four years later, seven in 10 patients had to ask permission of the RBMs.
"We appreciate that insurers are in the business of cutting costs. But which is more important—saving money or saving lives?" Dr. Graham said. "As physicians, we took an oath to 'do no harm.' It's time that health insurers help us fulfill that pledge by putting an end to the harmful behavior of denying coverage for molecular imaging tests."