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Better care coverage Decisions on tests and treatments must be based on much more than costs

A disturbing comment was voiced recently by a pediatric gastroenterologist at Women and Children's Hospital: "We end up treating people differently because of their insurance." That has been known for at least a decade, but it's still a profound statement about the way treatment can be determined and lives can be affected by what is supposed to be protection.

The comment, reported in a story about a dispute between a doctor and an insurance company over a medication for Crohn's disease, focuses on who gets to choose when a specific test or treatment is necessary -- the patient's doctor, or an insurance company.

And that, in turn, will be part of the debate that will intensify in America as President Obama addresses campaign promises of health care reform, and Congress moves to consider problems of the uninsured and underinsured. (Today's cover story for this section considers another issue, the computerization of medical records nationwide with stimulus bill funding.)

The ultimate goal should be individually tailored medical care decided on a case-by-case basis, not template treatments. There's room within that for insurance companies to evaluate best practices and push for the most proven methods and medications. But treatments that can prove cost-efficient by delivering health care more quickly are more likely to be assessed properly on an individual level; there can be incentives for data-driven preferences in medications and methods, but the guiding principle must be effective treatment and not just cost-shifting.

On his campaign Web site, Obama carefully laid out a plan to improve health coverage for all Americans, both businesses and people. Among other things, it included a proposal to require insurance companies to cover pre-existing conditions so that all Americans can receive comprehensive benefits at fair and stable premiums, and a new Small Business Health Tax Credit that would provide affordable health insurance to employees. Such measures would limit insurer cost-shifting, currently more profitable than treating certain classes of sick patients, and they should be pursued.

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