This commentary is by Marvin Malek, MD MPH. He is an internist from Berlin. He is an active member of the Vermont Medical Society and Vermont Physicians for a National Health Program.
The Legislature should pass H.766, the bill now being considered by the Vermont Senate that takes some first steps reining in the insurance company practice of “prior authorization.”
Here’s how prior authorization works: Let’s say that you’ve been dutifully paying your health insurance premiums each month and have had no medical issues. Finally, you develop a problem, have an office visit with your doctor, and your doctor orders various tests and treatments. You expect your insurer to simply cover the treatment plan. But the insurer has another option.
Your insurer can claim that it needs evidence to determine whether the doctor’s plan is actually necessary. This is known as “prior authorization.” The insurance company can require your doctor’s practice to complete insurers’ forms, fax portions of patients’ medical records (so much for confidentiality…) and schedule discussions between provider staff members at all levels — administrative staff, nurses and physicians — and representatives from the insurance company. Often, multiple forms are required, one after the next. Sometimes days go by between the practitioner ordering the test and getting a final ruling from the insurance company.
The practitioner — who has advanced training in medicine — is on one end of the phone line, while the administrative worker at the insurance company often has no medical training whatsoever. And of course, the practitioner has actually seen the patient, while the insurance company bureaucrat — generally situated in a cubicle somewhere far away — will never stand face to face and look the affected patients in the eye, ask them how they feel, examine them — or apologize for what they are doing.
This type of third-party intrusion is unheard of in other developed countries. Overall, insurers refuse to pay for 12% of prior authorization requests. In these situations, the patient can ask the doctor to appeal to the insurer and/or the government, develop a “plan B,” or the patient could simply pay the entire cost of the testing if they have the spare funds available. The majority of patients are unable to afford the cost of expensive tests. Several studies demonstrate that patients rarely fight back against insurer denials.
Repeated surveys have found that a large percentage of physicians report that denials of care result in palpable — often life-altering — harm to their patients.
When patients are confronted and unhappy with pricey medical bills, they may not realize that the bill they’re paying has to cover not merely the time they spent with the doctor, but also the doctor taking time off from actually treating patients to engage in conversations with insurance company employees about prior auth requests and denials. And their medical bills also have to pay the costs of hiring hypertrophied administrative staff to deal with denials of care, arcane billing procedures and incessant prior authorization requests.
In addition to paying for the administrative staff both in the doctor’s office and at the insurance company who are participating in the dance of prior authorization, there is another cost that is rarely considered in studies evaluating the impacts of prior authorization: the contribution of prior authorization to physician burnout. According to a survey compiled by the American College of Physicians, American physicians deal with an average of 2,340 prior authorization requests each year.
However, 2,340 is an average. The burdens of prior authorization are not distributed evenly among specialties: Primary care practitioners are disproportionately impacted. Turnover among primary care practitioners is very high, leading to understandable dissatisfaction among patients. When I speak with primary care practitioners, there is a running dialogue about how long they themselves and other primary care providers will “last” before they finally “bail.” The term “bail” refers to getting out of primary care practice to either retire or practice something other than primary care. Why do so many primary care practitioners bail after only a few years?
Dealing with the health needs of large numbers of patients and with often user-unfriendly software that forces them to work well into the evening most days, contending with user unfriendly electronic medical records and the stresses of finding ways to work with patients who are unable to handle unaffordable deductibles and co-pays are all burdensome enough. But the annoyance of dealing with a seemingly unending queue of prior auth requests can be the “straw that breaks the camel’s back.”
H.766 should most certainly be enacted. It sets limits on how long insurers are permitted to delay responding to prior authorization requests in routine and urgent circumstances, and sets guidelines for medication-related prior authorization requests. But it does very little to limit the total number of prior authorization requests insurers can impose on practitioners, or better yet prohibit the practice entirely. It’s disappointing that the Legislature isn’t doing more to relieve medical practices of gratuitous administrative burdens, including prior authorization. And the Legislature’s romance with value-based care schemes is actually making things worse.
But H.766 is certainly better than nothing. It will help a little. Beleaguered primary care practitioners will take whatever relief they can get. However, the Legislature should not declare victory: They have a long way to go to do their part in resuscitating the all-important primary care sector or Vermont’s health care system.
