Why preauthorization requests get rejected

It's not really surprising, but his blog highlights the importance of appealing rejected requests.

Milton Packer said...
Who Actually Is Reviewing All Those Preauthorization Requests?
Milton Packer thinks you should know how the system works

Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting. Don't worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do. However, the audience was a bit unusual for me.

Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care. I guess that explains why they had time in the middle of the day for an hour-long presentation. I gave my talk, but there were no questions. I had a few moments afterwards to speak to my audience. Since the physicians were not involved in patient care, I wondered why they wanted to hear a talk about new advances in heart failure.

The response surprised me: "We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures."

My jaw dropped: "I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients?" The answer was yes. I was really curious now. "So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities?"

Their answer hit me hard. "Oh, we've heard about those drugs before. We're asked to approve their use for patients all the time. But we don't approve most of the requests. Nearly all of them are outside of the guidelines that we are given."

I stammered. "I just showed you evidence that these new drugs and devices make a real positive difference in people's lives. People who get them feel better and live longer."

The physicians agreed. "Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."

I was astonished. "If the drugs will help people, how can you say no?"

Then I got the answer I did not expect. "You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare."

I responded quickly. "But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need."

One physician looked at me as if I were from a different planet. "You really don't understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare."

Before I had a chance to respond, he continued: "Plus, if I approve too many expensive drugs, I won't get my bonus at the end of the month. So giving out too many approvals wouldn't be a smart thing for me to do. Would it?"

I walked out of the room slowly. Although I had been invited to share my knowledge, it turned out that -- this time -- I was the real student. The physicians in the audience taught me a valuable lesson. And amazingly, none of them showed a single slide.

Which leads us to the question: Is our healthcare system sustainable??

I read somewhere that the leading cause of personal bankruptcy in the U.S. was medical bills....

Insurers' objective is to keep your money and their money.

JNF:

If you are going to compare our country with other countries, then perhaps you should also point out that other countries do at least have Universal Health Care. We don't. Consequently, many folks do not have any insurance.
I would guess that almost all of us HW folks do have health insurance.

This is not meant to detract from the sad fact that sick folks, often with little energy, get denied from having needed drugs. I am appalled that doctors -- working for insurance companies -- routinely deny such care in order to get bonuses. I suspect they use the "saving the healthcare system" line as a rationalization. It's all about the money. Here I always had the image of health care administrators -- not doctors -- denying care to get their bonuses/salary.

Mel

Shocker! I experienced this first hand. We had to submit our plan for SBRT three times before it was accepted.
The reason; it was considered experimental. The doctor who signed off on the denial was a.... wait for it....pediatrician.

Post Edited (searchinginla) : 11/10/2017 11:30:51 PM (GMT-7)

No surprise with what was in the originally posted article. My experience is that an appeal is worth the time, but be prepared for the long haul or they will wear you down. Even renewed prescriptions for the same medicine that the good doctor prescribed last year end up going through the gauntlet again.

Where I live (Sweden) we have a public health care system financed by taxes and available to all. We have similar problem I believe. The gap grows between the care that there are medical and technical opportunities to perform and the resources available to provide such care.
While the new expensive drugs can help severely sick with rare diseases, other care is taken away. A hard equation.
If we add incredibly much to a patient or a small patient group, then other patients will be without, we lose lives at the other end instead. So in some sense, we will face the problem that we must actually put a price on a life, how unpleasant it may be.

mattamx said...
.... I happen to be on Medicaid. I am only able to work half-time and so I simply cannot afford to buy insurance. ...... An issue I struggle with is the taxpayers having to pick up the tab for that drug....

And you are exactly the appropriate recipient for that kind of assistance! You want to work but cannot full-time due to physical constraints. Those in need should receive it. There's even some young military families getting food assistance because an E1-E3 (or even O1, O2) don't make a bunch of money.

Somebody mentioned the VA as an example of rationed health care - those of us in the system can fully relate to that statement. It took two weeks for me to be seen by a VA dentist for an urgent situation. I've been waiting for over two weeks just to talk to somebody about getting an MRI scheduled for my back.

I've been very blessed to have good medical insurance when working and when retired (I retired from a Fortune 5 company).

John T said:

"70% of our health care costs are used in the last two years of life, so perhaps that's where we should start looking."

That thought brings to mind one approach to cost reduction that
I'm not sure we have discussed all that much here in forum threads: the substantial changes in our social structure that have occurred over the past century or so, changes which have significantly impacted increases in medical costs.

(Granted this may be getting a little away from the original thread topic, but since it's cost reduction related, and especially in view of John T's above figure of 70 %, maybe I could make a quick comment about it).

In fact, some of these changes were discussed, as some of you who participate in the forum book club may remember, when we talked about Atul Gawande's "Being Mortal" a few months ago.

In his book Gawande made the point that even just a few decades ago it was common practice for families, as least in the U.S., to take in elderly relatives to live out their lives within the family structure, at a time when the hospice concept was still in the future (late 1960s at the earliest).

I know this is true because it happened in my family. In 1956, when I was 10 years old, my great-grandmother came to live with my father, mother and me. As a child I was pleased that "great-grandma" was coming to stay with us, but nobody told me at the time that she was really coming to die with us. I guess because of my age no one felt it necessary to inform me that she had been hobbled by a series of heart crises, had been given only a short time to live, and because it was family tradition, it was now incumbent upon the family, and not the state or some institution, to see to her care in her last days, by taking her in.

She stayed in the guest room, which became her room, and my mother became her caretaker, with very frequent visits by my grandmother ("great-grandma's" daughter).

I still remember after all these years the sad day when I came home from school in the afternoon one spring day to be told by my mom that "great-grandma" had passed on that morning.

It was the end of a cycle that had been going on in my family for generations: the older relatives staying with and living their final days with the younger ones.

Two points. The first is that this form of home care undoubtedly saved a great deal of money, that would have had to be spent, if my great-grandmother had had to go into some kind of institutional final care.

But the second point is: how many modern families are either in a position to perform this kind of home-based caregiving, noble as one would concede that it is, and regardless of possible cost savings, with virtually all of us working now, or living in different parts of the country? It’s simply no longer feasible for many (most?) of us, and Gawande makes this point in his book.

But to a degree I am perhaps the 21st century version of this kind of family-based caregiving. My mother, who turned 97 recently, lives in a senior-oriented condominium about a 15-minute drive from my house If necessary, I can drive to her quickly, if she has not already needed to push her Life-alert button. At this point I do most everything for her now (bill-paying, grocery shopping, transportation to appointments, and the like) while a daynurse makes regular visits during the week to take care of her personal needs such as bathing or taking medications. (Mom isn't officially in hospice status, but because of her age-related disabilities, she is very much in a position similar to that of my great-grandmother back in 1956).

Will Mom out of necessity have to move into a nursing home at some point? We don’t know yet, but for now I am, as noted, doing the 21st century version of taking into one's home, so to speak, the elderly relative.

And so far the only cost to Mom is that daynurse. She owns her condo, and so far Medicare and a small pension is taking care of her medical and other, small needs, primarily food and utilities. Contrast that to the cost of living in a retirement community.

Apologies if this has been a bit long, but the point I have tried to make is that if some way could be identified to involve families more in the care of their aging relatives, instead of relying on an institutional, and expensive, approach to achieve this, state or otherwise, perhaps at least some of the costs could be reduced.

My wife and I brought her mother over from England in the late 1990s. We'd reached a point where my wife was quite literally spending more time in the U.K. then here to get her mother to medical appointments, make sure the house was maintained, the refrigerator and pantry stocked etc. We owned a business at the time researching and writing newsletters so we put a separate phone line into her mother's house in England so my wife could keep a business phone and printer/fax machine there so she could bring her laptop and work on either side of the pond. It was costing us a fortune in air fares plus paying for people to check in on my MIL, cut grass etc. when my wife wasn't there.

I renovated our house so my MIL could have our dining room as her bedroom and our living room as her own space. We put those rooms on a separate heating zone so she could run the heat as high as she wanted. To make this work I also had to build a downstairs bathroom -- which required completely moving our back door and outside stairs, moving our own living room to the second floor, converting our attic to a master bedroom. Etc. A year's worth of my nights and weekends and another small fortune, even with my own labor. But in the end we were able to move my mother-in-law over here for the last five years of her life.

Over those five years she had an increasing number of medical crises - the most serious relating to a failing hip replacement she'd had done in the U.K. Long story short, the hip ultimately led to septicemia, several stays in the hospital followed by IV antibiotics administered at home by my wife and visiting nurses, and ultimately hospice at home.

Looking backward it is still hard to know at what point could we or medical professionals say this is the point of no return (or the point of throwing good money after bad if you are the insurer). But I think the call was pretty close to correct. When her doctors recommended hospice at home the alternative was further surgery that she may not have survived and if she did she would probably have ended up with an amputation at the hip at age 93, with little guarantee that the surgery would even extend her life. Her quality of life remained good over the nearly five years she lived with us after moving from England. And had she stayed in England, she would have certainly ended up in a nursing home and probably not lived as long or as well.

And now we are looking at something similar with my mother, who will be 93 in January. I was at her house today raking and mulching leaves. She's still in her own house, but the hospital admissions followed by rehabs at our house are coming more frequently.

I'm on the brink of ranting about siblings who are missing in action .. but some things are beyond our control.

I saw this published somewhere...Americans, all of us, spend on average $9500 a year on medical treatment. In India, that number is $250...In Pakistan, the number is $150...

Wow! Hold on guys we need to look at the other end of this story!!! Have any of you been to the emergency room lately? Who's there? A very young crowd with many young kids looking for some more well lets just say pain medicine for which all of us on here know what it's used for! My Grandson's mother is head emergency nurse in downtown Minneapolis ask her what the problem is over 75% of their time is spent dealing with this crowd of people she says the doctors are not able to spend time with real emergency patients because they are dealing with the crowd. So if we want to talk about controlling life in our senior years how about starting with this crowd at a young life cause were sure darn gonna pay much more over the years for these people than we are for the senior citizens who have paid into the system all their lives!!!! Ask the doctors nobody is talking about prevention!!!! When are we gonna wake up America? How many times did we go to the doctor when we were kids? I remember twice to get my tonsils out and the time I fell and broke open a cut on my head and my father screaming at me because how was he gonna pay to stich it up If I remember right it was 20 dollars at the local doctor in our little town who worked out of his house? I lived through 6 years of my dear mom going through hell with ALS in my opinion the worst disease there is but up until two days before she passed away she was fighting as much as her poor pain riddled body would let her!!! Did she deserve to live this long? Absolutely! My Dad served in Korea, they paid their taxes, paid their bills even tho they didn't make a ton of money! If everybody paid into the system and didn't abuse it there would be plenty of money!
Every store, every fast food, every gas station, every business in America is looking for help! If people would work and pay their fair sure and if we got the corporate welfare out of the medical gouging that's going on we could probably cut taxes for health care!!!!!

I understand the frustration that people can feel when they believe other people are gaming the system, and there are always going to be people who cheat any system. My opinion is that the vast majority of people getting entitlements need them. I work as a peer in mental health and it touches me that most of them say they wish they could trade their disability for the ability to work