Yesterday, a patient of mine came in complaining of pain in her neck radiating to her right hand with intermittent numbness. She is also having pain in her lower back which shoots like a knife to her right big toe. The pain has been going on for the past year or two, but the patient is working 2 jobs to make ends meet and does not have the time to come in. She is a wonderful historian and would rather grin and bear the pain than take medication for it. Unfortunately, the pain has gotten bad enough that she cannot walk >100 feet without having to stop and she is now having difficulty sitting due to the resulting neck pain. Last year, she went through PT and Chiropractic care with little benefit. So I decided to get both an MRI of the cervical spine and of the lumbar spine.
That is when the insanity started. The patient has a PPO, but in Virginia all patients with this insurance who need an MRI have to have prior authorization. My nurse called the intake nurse. Thirty minutes of grilling later, the nurse denied the authorizations stating that my patient could not be in that bad of pain because I had not prescribed a narcotic for her. My nurse countered that the patient was having weakness, but this did not matter. So, upon their request, we faxed in the chart. Today, we got the call that I needed to do a peer to peer call with the insurance physician. I called and had to leave a message for the physician to call me back. When he called back, he reiterated that the patient had no objective signs in the note (the patient did have a normal exam when I saw her) and that he was suspect of any problems because she really had not been placed on strong pain medications yet. He also felt that if only we had an EMG showing the radiculopathy then it would be ok to get the MRI. After I protested a bit ("is it really standard of care to get a EMG before an MRI??"), he decided to compromise. "I tell you what, which area is hurting her the worst? What if I approved that MRI but not the other?" I was somewhat dumbfounded except to say, "How do the results of the Lumbar MRI translate to what is going on in the C-spine and vice versa. That makes no sense at all" He then got mad, told me that he would have to push this up to the Neurologist for final evaluation and would get back to me. Click, the conversation was over.
So here I sit, furious. There are so many things wrong with this one case, that I'm sure I will miss some, but let me try to itemize them. From the treating doctor's perspective:
- The patient has a PPO and is paying a lot of money for this. That designation apparently means nothing any more.
Insurance companies place prior auths as roadblocks to care to decrease costs. The problem is that they have no data as to who is ordering inappropriate MRIs or too many MRIs, so they penalize everyone. No one at this insurance company can tell me whether I am an overutilizer or an underutilizer of the MRI scanner (I would be surprised if I order more than 2/month).
- The process of attempting to getthe prior auth wasted 40 minutes of my nurse's time and 10 minutes of my time not including the time it takes to print and fax the patient's chart. This time is UNCOMPENSATED and serves only to save insurance companies money. It does not augment my relationship with my patient. It does not improve my ability to take care of my patient. It does not assist my patient in any way.
- The frustrations of having to get prior authorizations make me reconsider whether to even order the test, which is indeed the purpose. But, when I begin to question my clinical judgment because of the roadblocks I might face, I subject myself to a higher risk of malpractice. So these useless procedural steps INCREASE my liability.
- The clinical algorithms are flawed and inconsistently applied. Show me a clinical guideline which states patients should be on narcotics before an MRI can be obtained. Better yet, show me one which states patients should undergo an EMG first. There aren't any because that is not standard of care.
- If the insurance doctor was willing to negotiate with me, then he has proven there is no clinical basis for his decision making. It is just about saving money.
- If I did not believe the tests were necessary, I would not have ordered them. Further, if a nurse or a physician who has never met the patient can diagnose and determine the appropriateness of therapy through the phone, then why am I even needed? Ironically, according to their own representative, this insurance company does not pay for phone call visits because their feeling is that it is impossible to diagnose and treat the patient outside the office.
So here is the real issue. My patient remains in pain because an administrator (physician or otherwise) has determined she is not worthy of the procedure. This decision will cost much more money in both the short and long term. Why? In the short term, I'll likely end up referring her to ortho, who will do X-rays, get the MRIs approved and maybe give her a few steroid injections before likely talking her in to surgery. In other words, her care now becomes fragmented, which will increase costs tremendously. And, because we learn from past experiences, my office will be more likely to refer other patients directly to specialists instead of ordering the appropriate diagnostic tests and waste untold amounts of time on the phone justifying our decisions. In the long term, these stupid administrative games sap the energy out of primary care continuing to kill the one area of medicine which has been shown to decrease costs.
Recapping, prior auths lead to no short term gains, no long term gains, a disruption of the doctor patient relationship, and a waste of the office's time all wrapped into a package which demeans the primary care doctor's judgment, increases his liability and encourages doctors to flee primary care like never before. Maybe the insurance executives share the same great insight as the financial sector executives. My fear is that if their vision continues, we will face the same nasty fate.
John Brady, MD, FAAFP