Insurers denying care | Prior authorization

Vinay Prasad, MD MPH; Physician & Professor
Hematologist/ Oncologist
Professor of Epidemiology, Biostatistics and Medicine
Author of 450+ Peer Reviewed papers, 2 Books, 2 Podcasts, 100+ op-eds.

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Twitter @vprasadmdmph

[bjs]

Excellent video. And once again, Dr. Prasad makes himself a target by telling the truth.

[trevfit]

As physician, the frustration occurs largely because treatment protocols mandated by insurance carriers do not always follow the science. What mystifies most of us is who writes their protocols governing the allocation of care. Compound that with the mystery about how treatment protocols required by insurance carriers are generated. Then, we must deal with reviewers who most likely have never treated a patient or the actual condition at hand. This is to say nothing of peer-to-peer conversations which can be even more frustrating. The "peer" doesn't even work in the same specialty as the one requesting the care. I understand the need to ensure requested care falls with acceptable guidelines, but there is a stark difference between guiding healthcare delivery and interfering with it.

[Jmanp]

25% of my job as a PA now is about prior auths or peer to peers. They deny everything unless it meets an arbitrary algorithm. It’s not medicine

[larschapman]

I just had an MRI prescribed by my doctor denied TWICE by insurance this last week. Evidently big insurance knows what is best for me more than my personal doctor.

[teresabenson]

Thank you for this! I'm so impressed with your willingness to post an honest view of the prior auth situation, even knowing most of your viewers disagree and you might lose some. I really appreciate your continued fairness and nuanced discussions of all these issues.

[olibertosoto]

Funny you brought up the self implosion of the Roman Empire - we're headed in the same direction but healthcare is the least of the worries at the moment.

[boatman]

Thumbs up for Vinay having the courage to speak truth! I hate insurance companies for the many problems they have caused me as someone 52 years of Type 1 diabetes. Forcing me to switch from a brand of insulin that works for me to a brand that doesn't to save $5 bucks via a middleman discount makes no cents (pun fully intended). But I totally agree that in the real world of medicine more than a few procedures waste of medical resources partially due to incompetence and partly due to maleficence. This video says more about the NYT than it says about health malfunction. Their journalism is getting worse and worse and worse and their circulation a d page count is getting smaller and smaller and smaller. Worse yet they apparently aren't even reading their own newspaper because Elizabeth Rosenthal, one of their own columnists, has repeatedly exposed the cost + 20% clause, most recently in her definitive book "An American Illness." Anyone truly wishing to understand the roots of the high costs and poor outcomes of American medicine should read her book which explains in great detail the numerous causes of both.

[Argentum]

As a MRI Tech who has to help Prior Auth get pushed through for outpatients I appreciate your balanced and nuanced take because I feel the same way. Some referring physicians refuse to learn anything about Radiology even though we try to educate them and they order the most unindicated and frivolous MRIs for the wildest differential diagnosis eliminations. In my opinion its doing the patients more harm than good with both the financial and emotional hit of doing such a procedure (MRI is very hard on patients). On the other hand I've called physicians directly begging them to consider doing a Peer2Peer appeal to Prior Auth denials based on the prior imaging evidence and many will refuse because its too much work even though we have compelling evidence their patient has a cancer.

It is so incredibly frustrating to me to navigate this broken healthcare system, moral hazard and injury for all - all around - all the time.

[WalkerOne]

Thanks for shining light on the other side of this debate.

[ЧитаДрита-шю]

As a pharmacist, I hate prior authorisation. My patients think I’m denying them. Terrible.

[ChrisCapoccia]

prior authorization is a crazy way to manage care. there are lots of complaints about a national health plan some other countries have, but prior authorization and insurance companies beating you down with bureaucracy is generally much worse. yes, you might find some oddball cases where doctors are picking unproven unwarranted treatments, but everyone knows plenty of cases when prior authorization and out of network treatments just lead to excuses from companies that have way more bureaucracy and time to waste than patients and people give up and get frustrated with trying to get insurance to pay for completely warranted treatments

[liz]

I watched a story about how insurance companies are outsourcing prior authorizations, and they reward the companies who maintain a 50% denial rate. So what happens is a double amputee needs a wheelchair, and bc his doctor didn’t include how being a double amputee affects his ability to walk (I can’t even….), he was denied a wheelchair. So the doc resubmits the request, and he was granted a wheelchair on the second one. This counts as two separate patients—TWO—even though it’s the same person. So that company gets to report a 50% denial rate. An amputee being delayed in getting a wheelchair may not kill him, but what happens when it’s a treatment for an aggressive cancer? Ppl die before it gets approved. It’s pure insanity. I get that there are two sides to this, but it’s also true that the insurance companies employ a business model that says “deny, delay, defend”, and it’s costing ppl their lives, or at the very least their quality of life.

[stevdaughtr]

My father got a liver transplant. He was given hepatitis C during the Vietnam era in the army, as many of the servicemen were, but didn’t find out they had it until they were very sick. Gave me 10 more years with him.

[darlafitzpatrick]

Thank you for this. I worked for three different health insurance organizations (all of them not-for-profit orgs) going back to 1996 and the bill that became HIPAA law and, later, when the PPACA was passed in 2010. It's hard to explain to people that insurance can never pay for everything a doctor or patient wants, because it would fail in about a week. The fact that health insurance exists at all, and that (until recently) most people were priced out of it unless they were covered under a workplace group plan, is an accident of history. It's a highly imperfect system, and certainly for-profit orgs have an incentive to wring more money out of patients, but it is not and cannot be a free smorgasbord for every unproven or questionable treatment one can imagine. I appreciate you pointing that out and injecting common sense into the discussion. People imagine there must be a malicious human who looks at every claim and declares "yes" or "no" based on their mood that day, and that's just not how it works.

[flybrand]

For your non hospital listeners - a simple clear example of “this is the process of prior authorization” would be useful.

[Saradoc]

I'd love your take on the WPATH files. I think it's another example of ideology being more important than data and what's best for patients.

[markmcla]

I nearly lost my colon because of the delays with prior authorization. The medical schedulers and insurance people really put me in a bad place. I eventually had to check myself into the emergency room and get hospitalized before I could receive an expensive medicine called Remicade. -Although this medicine is expensive, it worked miraculously on me. There needs to be some sort of improvement to the system....

[TheMedicalBillWhisperer]

As a patient advocate, I often request authorizations (many Drs don't bother or don't know how). If the treatment is "serious", deemed expensive, or is long-term, 2 supportive medical opinions, proof of "standard of Care", history of failed traditional options and inclusion by medical policy are the minimum needed to present a case. I worked in oncology for 6 years, and you're right, the only treatments denied were off-label and even many of those were authorized if listed in the NCCN. What seems to be denied a lot these days are treatment or therapy by out of network providers, "last-ditch" measures without trying less aggressive and more conventional measures and (of course!) IVIG. The rate of denials has been getting worse, even for extensions of existing authorizations for tx proven beneficial, safe and medically necessary.

[kma]

I"m so glad you posted this. When I clicked based on the title, I was waiting for a diatribe about how onerous the process is, and to be fair, for some treatments, and especially with some insurers, it's a nightmare. As a person who has filled these out, I've had the headaches. As a patient waiting for the treatments, believe me, those headaches get amplified by the fact that you're unwell and this is your hope on the line. But as you rightly point out, someone's got to watch the piggy bank. We have a broken healthcare system that disconnects the guy whose bank account gets drained from the decision to spend. The responsibility for weighing the value of a treatment is transferred to the doctor who's suppose to inform the patient but often does a half-..ssed job of it, and to the insurer who has no personal stake at all in the decision and only cares about the bottom line. When you have people with different agendas and motives making the decisions instead of the guy who actually has to pay the bill, we need someone to step in and be the patient's voice, not just his voice of desperation (the doctor) and not just his voice of reason (the insurer). We need both to prevent waste and quackery. Yes, the process should be streamlined, efficient, and transparent. Yes, we should have an appeals process. I can't think of any insurer that doesn't do these things with their PAs. They're a necessary evil, so if they need reform, use a scalpel and not a sledgehammer.

[wtfmimshag]

Nothwithstanding its reputation for socialised medicine, Australia has a significant private healthcare system funded largely through individuals purchasing insurance on a voluntary (albeit tax incentivised) basis. Our insurers are passive payers - if a hospital/doctor puts a claim in, the insurer pays it. Obviously there are integrity processes, but there's no right of veto (outside of agreed policy coverage). The insurance is becoming unaffordable. Govt tries to supress premiums. Insurers try to squeeze doctors and hospitals. Something has to give.