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

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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24 October 2019 Blog Post: Administrative Waste in the Primary Care Setting: Prescription Refills.

24 October 2019 Blog Post: Administrative Waste in the Primary Care Setting: Prescription Refills.

Our first installment of what will likely be multiple posts on Administrative Waste in the Primary Care setting… Today: Prescription Refills.
 
If you missed our post from October 19th, we promised to identify some sources of administrative waste highlighted by a The JAMA Network article highlighting the $935 billion that is lost without tangible benefit in our healthcare system annually. The authors, while identifying the scope of the loss, offered no meaningful solutions. We will try to help them with that.
 
Each day Santa Monica Primary Care we handle anywhere from 20 to 30 prescription refill requests. The bulk of these requests come via our E-prescribe system to which I was an early adopter and remain a strict adherent. There are a number of advantages to adopting a fully electronic prescribing system, the most compelling of which is patient safety. (More on this at: https://www.healthit.gov/…/state…/eprescribing-adoption/)
 
An additional consideration for our practice when refilling a medication is state guidelines. Particular states limit renewals to 12 months while others allow a longer time period, for example, a 90-day supply with four refills – a 15-month window. Why does this matter since we are in California? It matters a lot because we may be filling prescriptions in other states for patients who live elsewhere or are traveling. Additionally, many patients are now receiving prescriptions through mail order with fulfillment centers in Missouri, Arizona, Rhode Island among others.
 
What is fascinating (and sadly true) is that “work of prescription renewal has become so ingrained in practice that many physicians no longer recognize it as waste (Family Practice Medicine; Nov-Dec 2012).” This article goes on to point out that “physicians commonly renew scripts for an arbitrary number of refills, thus guaranteeing unnecessary work for themselves and their staff a few months later” (also sadly true).
 
Fortunately there is a solution! The solution is to synchronize prescriptions around the annual visit, providing sufficient refills to last until that time, and to ensure that the next annual visit actually gets scheduled
 
We are often asked our “office policy” (or receive feedback via Yelp/Google) regarding medication refills and the annual visit. Our policy is really a philosophy: 1. Ensure that the medication is working for you and remains appropriate. 2. Evaluate for any potential side effects of the medication that may have developed. 3. Integrate the medication’s use across all of the patient’s conditions. 4. Confirm that there are no drug-drug or drug-disease interactions.
 
As eloquently said in a KevinMD.com blog focused on this issue: “So, when we ask you to stop in for a brief visit, it’s not because we delight in hassling you or are hungry for your co-pay. We’re trying to protect you and to keep you well. Doesn’t this seem like the right prescription?”
 
And… it reduces waste in the medical system.
 

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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21 October 2019 Blog Post: Intermittent Fasting

21 October 2019 Blog Post: Intermittent Fasting

Anecdotal results on intermittent fasting as a way to manage weight and glucose levels have been exciting. I have seen a number of patients benefit. However, like most dietary approaches (beyond the tried and true – “fewer calories, more exercise”), there has not been objective evidence to support its use.
 
Now, however, a meta analysis published October 9th in The Journal of Clinical Medicine showed that the intermittent fasting diet was associated with a significant reduction in BMI, fasting blood glucose levels, and homeostatic model assessment of insulin resistance levels, when compared with a non-fasting control diet.
 
Intermittent fasting diets encompass the four following major approaches:
 
– Alternate-day fasting: no calories on fast days
– Alternate-day modified fasting:
<25% of baseline energy needs on fast day
– Time-restricted fasting:
restricting food to specific time periods of the day
– Periodic fasting: fasting only 1-2 days per week
 
Interestingly, there remains a circadian rhythm effect. Although this current study was unable to evaluate it fully given the diversity of interventions, it appears that consuming more calories in the morning could significantly improve weight loss and insulin resistance, while skipping breakfast may lead to an increase in stress hormones.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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20 October 2019 Blog Post: Health Care Expenditure in the US is Wasted

20 October 2019 Blog Post: Health Care Expenditure in the US is Wasted

Earlier this month, The JAMA Network published a not entirely surprising finding that approximately 25% of the health care expenditure in the US is wasted. The estimated total annual cost of waste was $760 billion to $935 billion. As a point of reference for those of us who don’t routinely dabble in the billions, the Gross Domestic Product of the Netherlands in 2019 is estimated to be $994.77 billion.

Let that sink in. We waste the GDP of the Netherlands annually. Just on healthcare. Gone. Poof. With nothing to show for it.

It gets worse. Really.

As quoted in the New York Times, William Shrank (@WillShrank), a physician who is chief medical officer of the health insurer Humana and the lead author of the study, said, “One contribution of our study is that we show that we have good evidence on how to eliminate some kinds of waste, but not all of it.”

Wait what? You don’t have enough ideas?

Further, according to the Times’ article, “the largest source of waste, according to the study, is administrative costs, totaling $266 billion a year. This includes time and resources devoted to billing and reporting to insurers and public programs. Despite this high cost, the authors found no studies that evaluate approaches to reducing it.”

So you’ve identified the biggest source of waste but have no ideas as to how to address it?

Well, Dr. Shrank, I have an idea. Why don’t we look at CEO compensation? Surely that is a purely administrative cost as I am unaware of any CEOs that are involved in direct patient care as part of their employment. Also, these are the individuals in charge of this wildly wasteful system.

Lets start with Dr. Shrank’s CEO – Humana’s Bruce Broussard. His SEC filed 2019 compensation totals $16,3 million. The top 5 senior executives at Humana combined made $36.4 million. And, to be fair, this level of compensation is not out of bounds for senior executives of health insurance companies. Total compensation for Daniel Loepp, CEO of Blue Cross in Michigan was $19.2 million in 2018, UnitedHealth Group CEO David Wichmann earned a $18.1 in 2018, CVS Health CEO Larry Merlo made $21.9 million and Anthem’s CEO Gail Boudreaux made $14.1 million.

For most, there is no attempt to justify these salaries. At least Mr. Loepp tried. “We are keeping health care affordable to the best of our ability here in Michigan,” a Blue Cross spokesman said. “We think he earns the money that he makes.”

It gets worse. Really. There are more CEOs to consider.

A Forbes article from June 2019 showed that among the 82 largest “not for profit” US hospitals, 13 organizations paid their top earner between $5 million and $21.6 million; 61 organizations paid their top executive between $1 million and $5 million; Only 8 organizations paid their top earner less than $1 million. Why is this important? Because 1 of every 7 healthcare dollars is spent at one of these institutions. In 2017, collectively, $297.5 million in cash compensation went to the top paid executive at each of the 82 hospitals.

So in about 30 minutes of research I have tallied the following:
1. 62 health care CEOs made a combined $1.1 billion in 2018
2. 82 “not for profit” hospital CEOs made $297.5 milllion in 2017.
 
In sum: 144 individuals : $1.4 billion dollars.
 
Again, for those of us who don’t dabble in billions, the GDP of the Solomon Islands (population: 611,343) is $1.46 billion.
 
This is only the tip of the iceberg as folding in senior executive compensation at these companies and hospitals will exponentially increase this total. I haven’t even included executive compensation in the pharmaceutical or medical supply industries either.
 
I suppose I shouldn’t be stunned that Dr. Shrank cannot come up with any ideas to reduce waste in the US healthcare system. When you are part of the problem,, it is hard to find a solution.
 
But I’ll be fair to Dr. Shrank and in posts that follow I will begin to highlight some of the tasks that we perform Santa Monica Primary Care that are wasteful and, more germane, suggest ways to improve. We are a small community-based practice but at least we’re willing to try.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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6 October 2019 Blog Post: Zantac undergone an FDA recall

6 October 2019 Blog Post: Zantac undergone an FDA recall

In case you missed the news, Zantac (generic Ranitidine – an H2 blocker used to treat acid reflux / heartburn symptoms) now has undergone an FDA recall due to the same alphabet soup carcinogens that have plagued certain anti-hypertensive medications (highlighted in prior posts). Attached is an excellent summary article by @JoshuaJGagne.

Part of the difficulty with this finding is that primary care providers like myself and our Gastroenterology colleagues have been increasingly recommending Zantac as a safer alternative to proton pump inhibitors such as Prilosec, Nexium and Dexilant for acid reflux. Why? This is because long term use of PPIs has been associated with: C. diff colitis, low magnesium, B12 malabsorption, iron malabsorption, hypergastrinemia, bone fracture and kidney dysfunction. Those aren’t sufficient reasons? OK – more recent studies have suggested an increased risk of pneumonia and dementia. Oh, and studies conflict as to whether or not there is an increased risk of death too.

But the risks of persistent acid over-secretion themselves are significant and include gastric ulcer, erosive esophagitis and even esophageal cancer. The discomfort of heartburn itself notwithstanding.

So have we painted ourselves into a corner? Certainly recommending a PPI doesn’t seem right given the above, although perhaps for short term use, such may be a reasonable choice. There are also other H2 blockers unaffected by the FDA recall. These are: cimetidine, famotidine, and nizatidine.

But perhaps the best advice comes in the final paragraph of the attached article – embracing lifestyle change. While not always realistic, there are particular dietary steps that one can take to limit acid reflux. Room temperature beverages can be helpful and limiting spicy dishes, coffee, alcohol, chocolate, tomatoes and other high acidity foods. In other words, anything good.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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