26 October 2019 Blog Post: Prior Authorizations and Peer-to-Peer reviews.

Our second installment of what will likely be multiple posts on Administrative Waste in the Primary Care setting… Today: Prior Authorizations and Peer-to-Peer reviews.
For those unfamiliar with these terms, welcome to yet another massive administrative hurdle faced by health care providers. Health plans give physicians a opportunity to explain to an insurance company employed physician why a treatment is medically necessary and appropriate either before a utilization review agent denies the request or after the denial. Of interest, some state laws don’t expressly state that a physician who handles a peer-to-peer call has to be of the same or a similar specialty. Further, some states only require that the patient’s physician gets “a reasonable opportunity to discuss with a physician the patient’s treatment plan and the clinical basis for the agent’s determination.”
A January 2018 survey by the American Medical Association (AMA) showed that during the course of the average work week, a physician completes an average of 37 prior authorization requests. Physicians and their staff spend an average of 16.4 hours per week completing prior authorization requirements for patient medicines, procedures and medical services that they may need. Some 90% of the surveyed physicians in this AMA study reported that the prior authorization process delays patient access to necessary care. And some of these delays are often lengthy, with 26% of physicians stating that in the prior week, they waited three business days or more on average to receive prior authorization decisions from health plans. The study found that on an annual basis, 853 hours were consumed by tasks related to prior authorization (Source: “Streamlining the Insurance Prior Authorization Debacle”; JC Corder. Mo Med. 2018 Jul-Aug; 115(4): 312–314).
What this means is that one-third of physicians are required to employ staff members who work exclusively on prior authorization duties. At @ [264764193647544:274:Santa Monica Primary Care] we also have a dedicated (although not full time) staff member who manages insurance authorization.
In my experience, I have never found this process to be particularly useful. For instance, when I call into a “peer”, it is obvious that they have some sort of checklist and will refer to “guidelines”. The most common insurance denial I get is for Orthopedic imaging, especially for MRI. Now this is a well founded concern as illustrated in a 2013 JAMA article showed that for MRI of the low back, “over half the requests were either inappropriate or of uncertain value.” Typically I reserve MRI requests for patients who have either not benefited from conservative therapy (e.g. Physical Therapy for at least 6 weeks, NSAIDs and heat/ice along with normal X-rays) or have significantly concerning or rapidly progressive symptoms. In these cases, the MRI is ‘approved’ after I dutifully read back my clinic note to my insurance peer who has the same note.
In other cases, a service denial can be galling and amounts to the physician on the other end of the line effectively practicing medicine, without ever having seen the patient. In the extreme, the insurance peer physician may not have even read submitted clinical notes. This isn’t fictional either. In 2018 there was well publicized case involving Aetna, wherein a medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care (for more details see: https://www.cnn.com/…/aetna-california…/index.html).
What I find most fascinating about peer-to-peer review and prior authorization requirements by private insurers, is that it is disproportionately emphasized. What do I mean by this? The stated goal of these reviews is to to reduce specific sources of clinical waste. This is a reasonable and worthwhile task – in theory. However, when one actually dives into the data it turns out that the costs of wasteful clinical procedures (overuse of antibiotics, inappropriate radiologic tests, avoidable Emergency Department use as examples) add up to only 2 to 3 percent of total spending on U.S. health care (source: Bentley et al; Milbank Q. 2008 Dec; 86(4): 629–659). This suggests that, despite the huge amount of U.S. spending that is wasteful, it is difficult to identify clinical procedures that are unambiguously wasteful.
I’m always looking for ways to improve my own clinical practice and become less wasteful. But if private insurance is having me spend 853 hours annually to jump through administrative hoops in order to do that, it makes me wonder if we could be doing something more constructive with that time.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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