Insurer Denial of Coverage: A Breach of Duty?

 

Despite the documented benefits, many insurance companies refuse to cover calcium scoring, citing its “experimental” nature or the need for more evidence of cost-effectiveness. But such denials may raise ethical questions. Are insurers inadvertently causing harm by limiting access to this critical preventive test? By not covering calcium scoring, insurers create barriers that prevent early detection and proactive treatment, allowing cardiovascular disease to progress unchecked in many individuals.

 

This practice contradicts the principle of “Do no harm.” Early detection through calcium scoring could prevent heart attacks and strokes, saving lives and significantly reducing healthcare costs associated with cardiovascular events, including emergency procedures like stenting and bypass surgery. Thus, denying access to this tool appears negligent, especially in light of the strong body of evidence supporting its effectiveness in preventing harm.

Negligence in the Face of Mounting Evidence

 

Given the overwhelming evidence supporting the benefits of calcium scoring, the ongoing refusal of insurers to cover it can arguably be seen as negligence. Negligence, in legal and medical contexts, refers to a failure to take reasonable care to avoid causing harm. Insurers have the resources and access to evidence showing that coronary calcium scoring is a valuable tool in preventing cardiovascular events. By ignoring or undervaluing this evidence, they are potentially complicit in preventable harm.

 

Texas and New Mexico have recognized this issue and enacted legislation that mandates coverage for calcium scorifng. These states are leading the way in prioritizing preventive healthcare over reactionary treatment, recognizing that the long-term savings from preventing heart attacks far outweigh the costs of the test itself.

 

If insurers across the board were to adopt similar policies, we could see significant reductions in heart attacks, strokes, and other cardiovascular events, translating into better health outcomes and lowered healthcare costs over time. The denial of such coverage, in contrast, perpetuates a cycle of preventable disease and higher future costs, both in terms of healthcare expenditures and human lives lost or affected by severe cardiovascular disease.

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We Don’t Have a Cardiovascular Health Care Industry—We Have a Cardiovascular Disease-Care Industry

 

The current healthcare system is overwhelmingly focused on disease management rather than health promotion. In the realm of cardiovascular care, this means the system profits from treating people after they’ve had a heart attack or developed chronic heart disease, rather than investing in prevention. This approach has created what can be described as a cardiovascular disease-care industry—one that thrives on the continuous need for expensive treatments and procedures after the disease has already advanced.

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Universal coverage of coronary calcium scoring is a powerful tool for improving public health, reducing healthcare costs, and addressing the ethical and economic challenges facing the healthcare system today. By providing early access to preventive care, we can reduce the incidence of heart attacks, strokes, and chronic cardiovascular disease, saving thousands of lives each year and billions in healthcare costs.

 

Moreover, universal coverage ensures that the benefits of improved cardiovascular health are shared across the healthcare system, aligning insurers’ interests with those of patients and healthcare providers. It also promotes equity, giving all individuals—regardless of income or geography—access to the preventive care they need to stay healthy.

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In the current U.S. healthcare system, most people stay with an insurance company for only about 5 years on average before switching to another insurer due to job changes, moving, or switching to a competitor offering better terms. This frequent churn in coverage means that any preventive healthcare investments made by one insurer often end up benefiting the next insurer, rather than the one that paid for the preventive services.

 

From an individual insurer’s perspective, covering calcium scoring may seem like a poor financial investment because they may not reap the rewards. By the time the preventive measures take effect, the patient might have switched to a different insurer, leaving the original insurer to bear the costs of the test but none of the benefits of avoided cardiovascular events.

 

This is a compelling reason to advocate for universal coverage of calcium scoring, as it benefits not just individual patients, but society as a whole.

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Negligence in Denying Access to Calcium Scoring: The “Mammogram for the Heart”

 

If mammography is considered a standard of care for early cancer detection, calcium scoring should be viewed as the “mammogram for the heart,” playing an equivalent role in preventing heart disease. Both tests are non-invasive, safe, and capable of identifying diseases before they become symptomatic, allowing for early treatment. In fact, coronary artery disease is the leading cause of death worldwide, surpassing even cancer, yet insurers continue to downplay the importance of calcium scoring in routine prevention.

 

Just as it would be unacceptable to deny a mammogram to a high-risk woman, it is ethically and medically irresponsible to deny calcium scoring to a patient at intermediate or high risk for cardiovascular disease. By failing to cover this test, insurers are allowing heart disease to progress unnoticed in patients who could benefit from early intervention.

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The cost savings from reduced heart attacks, strokes, and long-term disability would be distributed across all insurers, helping the healthcare system as a whole including Medicare save money in the long run. No one insurer would be disadvantaged by being the one to pay for preventive care while another benefits from the improved patient outcome.

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