Schul M W, King T, Kabnick L S
Unity Healthcare, LLC, Lafayette, IN, USA.
Phlebology. 2014 May;29(4):236-46. doi: 10.1177/0268355513479589. Epub 2013 May 6.
The emerging model of US health-care delivery is aimed at reducing costs, standardizing care, and improving outcomes. Although it is necessary for health-care providers and insurance carriers to work together to achieve those goals, insurers have the added duty of assuring physicians and patients that they comprehend the medical evidence and, based on that understanding, construct policies. Are US insurers meeting that responsibility or are they simply creating policies to serve their own needs?
The medical policies of several US health insurers were analysed. The goal was to see whether it could readily be determined if these carriers used evidence-based medicine consistently to create uniform policies for the treatment of patients with symptomatic varicose veins. The literature was also reviewed to determine whether increased insurance documentation requirements have affected cost reduction, standardization of care and/or improvement of outcomes related to chronic vein disease management.
There is a dramatic lack of uniformity among the insurance policies reviewed. Insurers appear to not choose important papers to create policy but use carefully chosen articles to reinforce what they want their policies to say. In so doing, conflicting policy criteria are being created. Complicating this inconsistency, rules for medical necessity are modified frequently, raising frustration levels among vein providers and their patients. What is clear is that costs are not being lowered, care is not being standardized and little is being done to prevent potential complications resulting from chronic vein disease.
Patients and physicians are increasingly ill-served by, and frustrated with, the clear lack of consistency in the medical policy criteria being created by US insurance carriers in covering the treatment of patients with symptomatic varicose veins. The contradictory coverage requirements, seemingly based on no understanding of evidence-based medicine guidelines, and total variability in reimbursement for various types of treatment options is particularly worrisome. Collaboration between venous treatment providers and insurance carriers, to create evidence-based standards of care, would be timely and beneficial in creating guidelines for optimal patient care.
美国新兴的医疗保健服务模式旨在降低成本、规范医疗服务并改善治疗效果。尽管医疗保健提供者和保险公司必须共同努力以实现这些目标，但保险公司还有额外的责任，即向医生和患者保证他们理解医学证据，并基于这种理解制定政策。美国的保险公司是否履行了这一责任，还是仅仅制定符合自身需求的政策？
分析了几家美国健康保险公司的医疗政策。目的是查看是否能轻易确定这些保险公司是否始终如一地使用循证医学来为有症状静脉曲张患者制定统一的治疗政策。还查阅了相关文献，以确定保险文件要求的增加是否影响了与慢性静脉疾病管理相关的成本降低、医疗服务标准化和/或治疗效果改善。
所审查的保险政策之间存在显著的不一致。保险公司似乎不是选择重要论文来制定政策，而是精心挑选文章来强化他们希望政策表达的内容。这样做会产生相互矛盾的政策标准。使这种不一致情况更加复杂的是，医疗必要性规则经常被修改，这增加了静脉疾病治疗提供者及其患者的挫败感。很明显，成本没有降低，医疗服务没有标准化，在预防慢性静脉疾病潜在并发症方面几乎没有采取任何措施。
美国保险公司在为有症状静脉曲张患者提供治疗的医疗政策标准上明显缺乏一致性，这越来越不利于患者和医生，并让他们感到沮丧。相互矛盾的保险范围要求，似乎是基于对循证医学指南的不理解，以及各种治疗方案报销的完全差异，尤其令人担忧。静脉治疗提供者和保险公司之间开展合作，制定基于证据的医疗服务标准，对于制定最佳患者护理指南将是及时且有益的。
