Diabetes-Related Complications: A Focus on Diabetic Macular Edema - Episode 18
Kenneth J. Snow, MD, MBA: I think one of the things for physicians to remember is that, ultimately, we are trying to have our members treated well. We recognize the work that they do and the care that they provide, and we, too, want our members to receive that level of quality care. To help facilitate that, we, at Aetna, publish our clinical guidelines because we don’t want these to be a surprise to anybody. We recognize that for the busy clinician, it is very difficult to go on to the various companies’ websites and to find out about all of the different issues. But for those providers who see a limited number of disease states, let’s say a specialist who is an ophthalmologist and focuses on eye disease, they can ignore many of our policies because they’re irrelevant to them.
For those [policies] that are pertinent to eye disease, it would be worth clinicians to take a look to see what the criteria are for certain therapies so that they’re aware of them. That way, when they’re requesting therapies, they’ll know if there’s any issue that they should make sure that we’re aware of so that we get the information that we need to make the right decision for that member. We’re at the limit of knowing what is going on with our patient. We’re limited by what information we receive. [However], the physician, since they’re with the member (the patient), can get all the clinical information they need. The more information that they can provide to us of why they’re making the decision that they’re making, [the more] that allows us to be smarter about making a decision.
One thing about having our policies out there publicly: any time we ever make a denial, we refer to our policies as well. Which policy was it that led to the denial? That allows the physician to look at that decision and decide whether that made sense. Sometimes, as I mentioned, it’s an issue of information that we didn’t have and that they can supply to us. That changes a decision.
It’s possible that our policy is not correct—that either we didn’t appreciate something or that there’s been new information that’s come out since the policy has been last reviewed. We try to review them frequently, but we don’t claim that we’re always perfect and that we’re absolutely up-to-the-minute on every single policy, no matter how hard we try. One way that we can be educated is by physicians out in the field who are taking care of patients.
If they see something in a policy, either a study that’s been missed or some new information that’s come along, or a reason why it no longer makes sense, bringing those to our attention does prompt our clinical policy committee to take a look at that policy and, based on this new information, ask, “Do we need to update that policy? Do we need to change it?” We get that on appeals. Providers will provide new literature—new information. That may be what prompts the change in our clinical policy. We definitely encourage folks, if there’s a decision that they disagree with, to send us literature to support why it is they feel we got it wrong.