Meeting with the DMHC yesterday
After many months of trying to get this to happen, Dr. Larra and I had a 2.5 hour meeting with officials at the DMHC in Sacramento yesterday. The topics for discussion were:
1) The DMHC has a policy statement that pre-op dieting and mandated weight loss are improper, as there is no evidence-based support for doing so. They will (almost?) always order the insurance companies to waive the requirement IF the patient is informed enough to know they can file a grievance with the DMHC -- so WHY doesn't the DMHC find some way to order the CA insurance companies to stop requiring people to do so in the first place?
2) The DMHC has consistently overruled denials for the DS for the last 4+ years*. So WHY doesn't the DMHC find some way to order the CA insurance companies to stop denying the DS in the first place?
* Here are the stats I complied from the DMHC IMR website:
Cases in which the duodenal switch was requested
So this is what we learned -- which was NOT what we were hoping to hear, but which gives us some ideas about how to proceed:
1) The DMHC's regulatory authority does NOT extend to "enforcing" their policies by making the insurance companies change their policies, unless they are enforcing a specific law (e.g., a law mandating coverage of post-mastectomy reconstructive surgery).
2) They can only overrule medical policies (which are presumably put in place by MEDICAL directors at the insurance companies for EVIDENCE-BASED and MEDICALLY-SUPPORTED reasons [HA! we know they are profits-driven]) for INDIVIDUAL cases, by pointing to their study-based policies (like the one overruling the diet requirement) or based in the IMR process.
3) Therefore, they cannot do what we requested, which was to find some way to FINE the insurance companies or find some other way to make putting patients through these torturous procedures more expensive than changing them. Dammit.
4) However, the DMHC DOES have the authority to question these policies and ask the insurance companies to review and justify them (Larra -- does that accurately describe what they told us?) -- although it remains the prerogative of the insurance companies to change them.
5) The DMHC officials suggested that one way -- albeit slow -- to effect change with the insurance companies is to keep up the pressure by continuing to appeal, file grievances and requesting IMRs, and increasing the body of evidence that the policies are improper, thereby making it harder and harder for the insurance companies to internally justify maintaining the policies.
So it appears that on a global policy basis, without specific laws to enforce, the DMHC is a lot more toothless than we had hoped, because they have to give deference to "medical policies" that are supposedly endorsed by the insurance companies' medical directors. However, on a case-by-case basis, they still can help by overruling denials and diet requirements, and they are now even more aware of the issues than they were before, and they promised that they are looking into ways to help us out.
So, the take-home lesson is, in order to effect change, we need to keep up the pressure on the insurance companies, and NOT let them get away with applying their improper policies and requirements. One good thing we learned -- when people file for an IMR, which the DMHC contracts out with a for-profit company called CHDR/Maximus, the insurance companies have to pay for them. Of course, the costs of doing so for the few people who DO know enough and bother to challenge these policies is likely MORE than made up for by the benefits the insurance companies reap by keeping these obstacles in place, because so many people are delayed and even discouraged entirely from going through the process and thus save the insurance company more money than the appeals cost them. And this will be so until we make it cost them more to fight the appeals than they are saving by putting their patients through these awful procedures.
I am somewhat disillusioned, but still committed to continuing this fight. I hope we can keep the pressure up by encouraging people to fight against these unjust policies.
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