Doctors are being driven out of primary care

The biggest detriment to health care and a burdensome cost to primary care physicians is pre-authorization (PA). This is one of the drivers behind providers leaving primary care. Also, If you want to improve the quality of medicine in this country, take control of medical care away from the insurance companies and give it back to the providers.

So what are pre-authorizations? Many health insurance companies require that health care providers obtain approval from the patient’s health care plan before proceeding with testing, procedures, treatment or medication. For example, unlike traditional Medicare (which may require pre-authorization for durable medical equipment), Medicare Advantage plans generally require prior approval for a number of services, such as CT scans, MRI’s, PET scans, nuclear stress tests, procedures, therapies, surgery, etc. If approval is denied, then the plan will not cover the cost of the service. In reality, due to the expense involved, if an insurance company does not approve a service, it does not get done.

Pre-authorization denials do not necessarily translate into lower overall health spending. A study by Priority Health found that while initially lumbar surgery decreased, it subsequently increased in the following years with the unintended consequences of increased costs. This was probably due to more extensive surgery now being required. The use of pre-authorizations can also result in poorer outcomes due to delays in care or care not received.

Step therapy for prescription drugs or, “fail first,” is a tool used to manage drug utilization. Step therapy requires that patients try lower-cost drugs and fail therapy goals with them (and in the interim perhaps suffer harm?) before a costlier or brand-name drug will be covered. In a study conducted by the Journal of Managed Care Pharmacy, it was found that those who were prescribed higher priced newer medications requiring a PA that were denied had higher overall medical costs the following year. The authors conclude that failure to receive medically necessary medication could be a factor contributing to inadequate control of diabetic conditions which may result in an excess of resource utilization and increase costs for treating the disease and other comorbidities. This extra expense is most likely passed onto the consumer by the insurance company in the form of higher premiums.

Step testing: In this scenario, insurance companies may recommend a test before the test that the provider wanted approved. When the test recommended by the insurance company is found not to be helpful and the test the provider wanted to order in the first place is finally approved, the cost of the unnecessary test is then part of the overall cost of health care. This extra expense is also more likely than not passed on to the consumer.

It is my opinion, that while insurance company profits may decline without a mass of pre-authorizations, the overall cost of health care and harm to patients would also decline by avoiding unnecessary delay, or the inability to provide care at all. Also, the American Medical Association several years ago found that physicians complete an average of 31 PAs a week. ( And even more when one counts denial appeals). This results in a financial and staff time burden on the physician’s office which must absorb this cost as our fees are set by insurance companies. Insurance companies can merely pass it on to the consumer.

This brings up the next point. What is the liability of health plans when care is denied and a patient suffers harm? Usually, there is none. The ERISA (Employee Retirement Income Security Act) is a federal law created in 1974 that governs how employers provide benefit plans to employees. It basically protects health plans against tort claims of negligence and malpractice. It does allow under a breach of contract claim the cost of the service denied. In other words, if a stress test was ordered and denied and harm was suffered, what could happen is only the cost of the stress test would be awarded.

ERISA preemption on the ability to bring medical malpractice and negligence claims against health insurers, namely health maintenance organizations (HMOs), is a cause for concern. In Corcoran v. United Health Care, a patient was pregnant and her doctor recommended complete bed rest and hospitalization so he could monitor the fetus. The patient’s doctor sought pre-certification from her insurance company for the hospital stay. The request was denied and authorized only 10 hours per day for the services of a home health nurse. Although the patient entered a hospital, she was forced to return home after her health insurance refused to cover her hospital stay. Subsequently, the fetus went into distress and died at a time when the home health nurse was not on duty. The case was dismissed in federal court.

This law needs to be either updated by Congress, or rewritten on a state level to clearly allow tort claims if a patient suffers harm from a denial of service. It is outdated, since it precedes the existence of HMOs and pre-authorizations, and did not envision that such would happen. The cost of medicine would not increase if the ERISA act were repealed since they would only face a lawsuit when a patient suffers harm from their actions. And if they claim they’re doing a great job, then they have nothing to worry about as there wouldn’t be any lawsuits Eliminating this act would hold insurance companies responsible for their actions. Eliminating pre-authorizations would attract primary care providers to Connecticut.