Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature.
BACKGROUND
There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care.


OBJECTIVE
To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians.


METHODS
Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy.


METHODS
Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists.


RESULTS
Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01).


CONCLUSIONS
Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.
Finkelstein
B S
BS
Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA.
Silvers
J B
JB
Marrero
U
U
Neuhauser
D
D
Cuttler
L
L
D001827:Body Height; D002648:Child; D003657:Decision Making; D004704:Endocrinology; D005194:Family Practice; D006130:Growth Disorders / Q000188:drug therapy* / Q000191:economics*; D013006:Growth Hormone / Q000191:economics* / Q000627:therapeutic use*; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000706:statistics & numerical data*; D007356:Insurance, Pharmaceutical Services / Q000706:statistics & numerical data; D008484:Medicaid / Q000706:statistics & numerical data; D008962:Models, Theoretical; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D011320:Primary Health Care; D014481:United States
D013006:Growth Hormone