Prior Authorization: Care, Delayed | EP 3

Everybody welcome to the healthcare and cover show. I'm Joe Ratino. I'm Wengel Potter. Wendell and I have worked together for ten years. We've crisscrossed the country from New Mexico to Alaska, Missouri, and Puerto Rico. Telling people stories, documenting the fine print, and yes, uncovering which really wrong with America's healthcare system. Prior to authorization is a time suck. Folks go into their doctors because they think that they have something wrong with them. And then the doctor says, "Yeah, you do have something wrong with you. We need to get you meds or treatment." And the insurance company steps in and says, "Hold up." No. And what it does is it makes people wait by the phone waiting for authorization to get the care that they need. Right. And what doesn't wait is that disease that's inside their body. The mass and their gut. That doesn't wait. And people get sicker in America. People are saying they're waiting for an insurance company to tell them whether they can get the care that they need. They're sitting there getting sicker and sicker. And it's a game that forces folks to like pay out a pocket for care that they immediately need. It's a game that forces doctors to go out and beg and plead with insurance companies to give their patients the care that they need. And it's also a game of abandonment. Like, folks just abandon getting care that they know they need. And insurance companies, it works out great for them because they're able to take in the premium dollars and then not have to pay out on the claim. I think it is the real thing that's keeping Americans sicker and dying sooner in this country. And it's a kind of a recent phenomenon. It hasn't always been this way. Even when I first started working in health insurance, prior authorization wasn't used all that much. But now it's used increasingly. And more and more people are understanding what that term means. And it keeps a lot of people, like you said, from getting the care that they need. A lot of people in this country die early because they think their insurance company will cover what they need. The policy says they're going to cover it. But an insurance company employee or bureaucrat somewhere, 2000 miles away might say, "Now we don't think we're going to pay for this." Because we don't think, in our opinion, it's medically necessary. And folks know you as like the health insurance was so blow or guy. And there's a lot of. There was a couple of reasons why you came out of the industry and told the world what you know. But one of the main reasons had to do with prior authorization. Yeah, it did. The tragic death of a California teenager last night, just hours after her insurance company reversed itself and agreed to pay for a liver transplant. Now, her. We got a call in a few days before Christmas from a reporter in Los Angeles about 17-year-old girl in the San Fernando Valley who needed a liver transplant. Covered benefit. She was in a plan. There was her father's plan. Mercedes Benz plan. It was a Mercedes plan. And she was a patient at UCL Medical Center and a match had been found. The liver waiting for Nettelines Archeesian. The family arrived at the hospital expecting to wait for Nettelines to come out of surgery. But when they got there instead, the surgeon took them aside and said, "I'm sorry, we can't go forward with this because Signe hasn't given us clearance." And the family didn't know what was going on. They knew that a transplant was covered under their policy. But they were told that unless they had like $7,000, they were not going to be able to proceed with the surgery. And the family didn't have that much money. So that liver had to go to somebody else. And in my career at Signe, I led a team of communications professionals. And one of the things that we did day in and day out was dealing with reporters who would call wondering why Signe was refusing to cover something that a doctor said a patient needed. And we were pretty good at batting those stories away. But the family was determined to try to get Signe to reverse that denial. Friends and nurses marched on the insurance company that had denied her a liver transplant. And again, we're talking about prior authorization here. The family was able to get so much attention focused on this case. More and more reporters started calling us about, "Well, why are you not covering this?" Calling you at Signe? Calling me at Signe. Yeah, my name and phone number during the back in those days. This was in 2007. My name and phone number was on their website. So people knew how to reach me. And so we started getting calls by the dozen coming in. And they were not just from Los Angeles. They were all over the country, became an international story. To the point that I had to tell the CEO what was going on that this is becoming a big PR problem, a nightmare for the company. So finally, the company decided, well, this is causing significant damage to the company's reputation. So the company decided in a meeting that I was in to reverse that denial and cover the transplant for netdling and circuasing. The thing that just approved that. The problem was that so much time had passed since the initial request for coverage was made and the surgery was scheduled five days had passed and netdling got sicker to the point that she was no longer eligible for a transplant. And of course, there was no liver waiting for her anyway. That had passed. And she died just five hours after a sickness said it would cover her transplant. And I'm a father. I could just imagine what this family was going through. And it was the -- that was it for me. It was a sprawl that brought the camels back. I couldn't continue working in industry where this was becoming more and more prevalent. And that was several years ago. 2007 you said. Yeah. It's 2026 now. Yeah. It's, uh, we're getting close to 20 years. And since then, the companies are using it much more than they were before. Doctors now have to spend an enormous amount of their time doing nothing more than staying on the phone. Literally on the phone with some bureaucrat at some insurance company trying to persuade that person to reverse it in the aisle so that they can care for the patient the way they know that they need to care for their patients. It's a real time suck for patients and doctors. In fact, it is a leading reason why we spend so much money on a administrative cost. And it's also a reason why -- increasingly, it's difficult for us where we had to spend time -- it takes so long to get an appointment sometimes with a doctor because doctors increasingly are having to spend time that they otherwise would use treating or seeing patients on the phone within insurance companies. And like you see it, like you go into a doctor's office, how many people are sitting at a computer not touching a patient? Right. Like they've had to build out all of their staff just to handle that part of their work. And that's what you can see. Usually there's a back room depending on how big the physician practice is. And in hospitals, it's the same thing. It's not just physician practices. Hospitals -- big hospitals -- have to have hundreds of people on staff who do nothing more. The only reason they have jobs is because of prior authorization, because they need to intercede to try to make sure that an insurance company is going to pay for what a patient needs who's in a hospital. So we've talked a lot about like how bad this is for patients. You're getting on to the subject of how bad it is for doctors. And we spoke to Dr. Wendy Dean, a psychiatrist who is the co-founder of moral injury of health care. And she writes a lot about this issue in a lot of different publications, but also for health care uncovered. Yeah. When we think about prior authorization, that is an insurance company saying, "We know that you've seen the patient. We know that you've done your assessment. We know that you've done your diagnostic tests or you want to do diagnostic tests. But we're questioning what we think is right. And so what that ends up doing is pitting the physician against the insurance company in order to get what the patient needs. We train for a decade or more to know how to take care of our patients to the best of our ability. And when we're following evidence-based medicine, and the insurance company says, "Yeah, but do you really need that test?" Yeah, but do they really need that treatment? to say, "Hang on, I made a promise to these patients, and I can't uphold that promise when these barriers keep getting in my way." And so that's really, I think, where the prior authorization piece of this moral injury comes in. So the definition of moral injury is betrayal, biological of authority, in a high-stake situation that causes you to transgress deeply-held moral beliefs, like the oaths that we took to put our patients first. So there's this sense of betrayal, but that can all, that very quickly, when I talk to my colleagues who are struggling, that very quickly becomes manifest as anger, frustration, a sense of demoralization. They sort of start separating themselves. They become sort of a depersonalizing experience where I can't escape this in order to survive it. I have to put up emotional walls. And so all of these things aren't necessarily named as moral injury, but they are the experience of moral injury, or experiencing the risk of moral injury. And Wendy, by the way, she was in private practice, and she worked in the military for several years. So she knows where that term came from. And it's from soldiers in the battlefield, often having moral injury from having served in a war-torn country and saying what damage a war can cause a community. And even to their own colleagues. But it's increasingly being used in healthcare to describe what clinicians in this country have to go through to try to get the care that their patients need. The roots of moral injury really started in the Vietnam War. And Jonathan Che is a psychiatrist who was working in the VA and was taking care of veterans of Vietnam. And he was treating them for PTSD with treatments that he knew worked for that condition. But they weren't getting better. And so he did what every good clinician would do. And he said, "Okay, I've been caring for them in a way that I think should work, and it's not working." So I'm going to question my diagnosis. And he started asking a deeper question of, is this really what I think it is? And what he realized was this wasn't PTSD, where someone is afraid for their life. This is something deeper. It was that these soldiers could not uphold the oath that they took. And this was a soul wound. This was a threat to their moral well-being. And I had been working in the US Army as a civilian and seeing what the folks in Afghanistan and Iraq were experiencing. And I started thinking, hang on. We borrowed the PTSD terminology. Maybe we can generalize moral injury as well, because it really feels to me very similar. It's not just that we're being asked to work hard, to work long hours and see hard things. It's that we're being kept from keeping the promise that we made to society as a whole. And I think prior authorization is a perfect example of where physicians feel unable to speak out and unable to make change because they're no longer independent. So when physicians were independent, insurance companies used to track this metric called physician abrasion. And that was how much harassment will a physician tolerate before they leave our network? And when a physician left their network, the implication that that had was that there was no longer sufficient physicians to see a patient in a timely way. And so that was powerful. They could walk away. They could make that choice. And that gave them leverage. Now that 70% are employed, they don't have the ability to walk away because their employer decides whether or not they're part of that insurance network. And so I think it's imperative to us that we really start looking at what is the abrasion of the system on the physicians that are still in it. And not just tweaking little bits here and there, not just tweaking how we do things. And making incremental change, but really looking at how do we reduce the friction of the system that makes it harder for physicians to take care of their patients and other clinicians to take care of their patients because honestly, nurses have some of the same challenges taking care of their patients. They don't have prior authorization, but they're spending more time on the computer than they are with their patients. They have more check boxes like they're struggling to. One of the things people say to me all the time is, you know, how do you do this work? And if I weren't optimistic about change, I couldn't do the work. But what I also say is that the bad news is that healthcare is really broken. The good news is that healthcare is really broken. So anywhere you start to make a change, you're going to make it better. So one of the and I work with this guy, Dr. Seth Gluckman. He's a former insurance and health system executive and he's now a researcher and writer that we've done a lot of projects with him. And this past summer, we were on Capitol Hill presenting a project that we did to some staffers on the hill. And it all went well and before we go on to Leap Town, Seth and I decided to go grab a beer and a burger. And so we're out and we're just like, you know, enjoying the moment, like, you know, calling victory on whatever we just presented. And Seth like stops our conversation and was like, Joey, I just want to let you know, like I had some early testing on something and I think that they found, you know, a mass of some sort. And you know, like we're talking about prior off here and it's bad enough that Seth was likely sick. It's bad enough that like his family has to worry about him and he has to worry about his self's work. Bad for me, like I'm just trying to have like a burger and a beer and he's telling me that he's sick, you know, like it's stressful. These are awful things. But to add to that and mind you, again, this guy is a former insurance and health system executive. On top of being sick, he found himself in like his own version of prior authorization helm that we spoke to him about. I had a test that showed that there was a lesion in my pancreas. And so I needed to get a follow up study, which was really important. And I thought it was something very straightforward. I am a physician. And so I thought it was going to be a slam dunk when my gastroenterologist put in a order for an MRI. And obviously I wanted to get the information as soon as I could because I was really worried about what what it was and what the diagnosis was and what the implications were to turn into a really hellish experience because initially the procedure was declined. Though I had to do a lot of arm twisting. There were a lot of delays. I spoke to a lot of people. And finally they ended up overturning the decision and I got it approved. And so I thought, well, now we're off to the races. I can just get this test done. It turned out that the first appointment available to actually get my MRI was actually months out. And then what I found out was the actual imaging provider that was going to do the study was having a hard time tracking down the actual authorization approval because all that they had access to was the prior one that was entered, which showed it was denied. And I'll spare you the details, but that took another couple of weeks for me to sort out. And so it ended up being what felt like a minimum part time, but at times full time job during that time period to sort out. And this was really hell for me. And this is as a former insider, someone who's worked in the industry, someone who's a physician. And so I can only imagine what people who do not have basic health literacy let alone an advanced degree like I had must go through. And then having to go through all this while they're also dealing with the same thing. dealing with their medical condition, whether it's cancer or some serious illness, it's just awful. And it's an incredible burden on people and families and is not humane. In addition to writing about his own prior authorization, Hell, Seth is also like health current covers resident expert on the new wiser model, which is when I always mess up this acronym. It's a very peaceful and inappropriate service reduction. Sounds really good. Yeah. Who wouldn't want that? But wiser is, it was just implemented by CMS and Dr. Oz at the beginning of the year. And what it does for the first time in Medicare history is put prior authorization on 17 different medical services with the use of AI. Seth could speak much better about wiser than I can. Wiser is a program that comes out of the CMS innovation center. And it is designed in theory to reduce fraud, waste and abuse. And in order to do that, it's using technology vendors to essentially insert themselves in the middle of the doctor actually ordering one of these tests or procedures for their patients. But this is the first time that Medicare is actually allowing companies to do prior authorization for things like spine surgery. And they're actually leveraging for profit technology companies. And so you're introducing a clear profit motive and incentive in terms of denying care. And so you'll have the effect of reducing cost of care, which is what the goal of this program is, except the problem is it's enriching for profit companies that are going to be using AI algorithms to essentially come up with their own criteria for justifying denials. And who's left holding the bag is our doctors and our patients that actually need this care for their own health and livelihoods. When wiser sounds like a real bad deal. You know what it is? And fortunately, we're getting some more media coverage of it, but also more attention on Capitol Hill. Absolutely. And there are members of Congress who really looked at this and Congresswoman Del Bine of Washington State has introduced legislation to address this, to make this unlawful to go forward with wiser. I think you see, the singers deserve smarter care act that she's introduced into Congress. And we spoke to her about that. What they call the wiser model, these pilots in six states across the country. It was rolled out very quickly, not much time for folks to understand what their goals were. I asked many questions from the Department of Health and Human Services about this, about the model, about how it would be implemented and the administration never replied. They are putting a burden on our health care system, a great burden on our health care system that's very expensive for everyone. And when patients are denied care or care is delayed, that's more expensive because people can get sicker, not get the care they need as quickly. So if we look comprehensively at this, this is nothing to do with saving money, despite what some folks may say. It creates delays for patients, headaches for providers, and worsens health outcomes. We have pushed in legislation that I've led to stop the wiser model, this pilot from going through until we have more information and answers. And we have strong support for the legislation. We're going to need ongoing bipartisan support to stop this. We need to do better. Make sure people are getting the health care that they deserve. Make sure that health care providers can spend their time providing health care and make things work faster. So we're going to continue to push for. So maybe just a few clarifying questions to end the show. So prior authorization, good for patients. Not good for patients. Prior authorization, good for doctors. Not at all. Prior authorization, good for health insurers. Great for health insurers. Helps them make a lot of money. I think that's our show. All right. Thank you all for watching and tuning in. Healthcare Uncovered is a reader-supported publication. Check us out on the substack and like and share wherever you watch or listen to us.