Pennsylvania's largest Blue Cross insurer, worried that too many members were getting their spines worked by chiropractors they didn't need - at a price of maybe $30 million a year in "unwarranted" costs - plans Sept. 1 to require prior authorization after eight visits, which Highmark Inc. has maintained was all that two-thirds of patients needed.
Leaders of Pennsylvania chiropractors are treating the insurer's new directive as an attack on their livelihoods and their patients.
The new requirements, using an approval system set up by Healthways, a Tennessee-based insurance-approvals standards firm, will also apply to Highmark's occupational- and physical-therapy patients.
"Millions of Americans insured by Highmark Inc. are about to have some of their medical treatments decided by a computer program, rather than their doctor or therapist," the Pennsylvania Chiropractic Association said in a statement Tuesday.
The "new software" will "begin making the treatment decisions for patients, rather than the doctor or therapist who actually examined the patient and made the diagnosis," the group said.
PCA president Daniel Schatzberg called the change "a chilling snapshot of the future of health care in America" and said the move recalled George Orwell's dystopian government in his novel 1984. The chiros are telling patients to lobby legislators and the state Insurance Department to block the program.
Highmark spokesman Aaron Billger says the insurer is trying to conserve dollars so it can pay benefits "when members need them, and avoid overutilization, which can lead to poorer outcomes." He told me the new approach is "fair and reasonable" and should help keep a lid on "escalating cost."
Will Independence Blue Cross in Philadelphia follow Highmark's lead? "By the end of this year, they'll be adopting it, as well," says Randy King, a former adviser to ex-Harrisburg Mayor Stephen Reed. King's Harrisburg firm, Triad Strategies, is working for the chiros.
Or not: "Independence Blue Cross has no current plans to implement a physical management medicine program," spokeswoman Judimarie Thomas told me.
Boss and prof
Since the 1990s, Harold Glass, Ph.D., has lived a double life.
A research professor of health policy (and former head of graduate-pharmacy studies) at University of the Sciences in Philadelphia, who also teaches classes at King's College in London, Glass on Tuesday sold his company, TTC, a drug-testing data firm.
TTC boasts the largest "clinical-trial cost benchmarking and analysis databases" in the world. The buyer was IMS Health Inc., a Parsippany, N.J., drug-marketing and data company. The price was not disclosed.
TTC's 30 workers are joining IMS, bringing the company's local total to 1,000. The company's U.S. operations and its SDI health-care-data unit are based in Blue Bell.
"It's rare to see anyone so extremely successful in both academic and business professions," said Mark Chesen of SSG Capital Advisors, a West Conshohocken investment bank that counseled Glass. "He's a Renaissance man [who also] plays the cello," said Chesen. "And he loves the Eagles."
Chesen, whose firm joined Neal McCarthy of Fairmount Advisers in guiding TTC, notes that this is the second time Glass has sold a testing-data company to IMS: The same firm bought Glass' DataEdge in 2000.
At that time, Glass says, he "returned full time to academics," but later found that DataEdge's drug-company customers were displeased when IMS sold the business to new operators. So he set up another, updated provider, with IMS's financial backing.
TTC stands for Tarheel Trading Co.; Glass holds a doctorate from the University of North Carolina ("Home of the Tar Heels"). He also has degrees from universities in England and California.
"Business and academics often don't come together in one place," Glass told me. "They are very different ways of looking at the world."
Contact Joseph N. DiStefano at 215-854-5194 or JoeD@phillynews.com, or follow on Twitter @PhillyJoeD.