This is a story about Prior Authorizations. The American Medical Association defines Prior Authorizations as “A health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage,” and the Hitchhiker’s Guide to the Galaxy describes the insurance company executives who invented this process as “A bunch of mindless jerks who’ll be the first against the wall when the revolution comes.” Doctors just define Prior Authorizations as “Oh no, not again.” One would imagine that after the involved process of history taking, physical exam, strategic work-up and diagnosis, and careful shared decision making between a patient and a doctor, the two of them could be trusted to come up with a treatment plan together. Insurance companies don’t believe this; or at least, pretend not to. Sometimes these processes are routine and streamlined enough that they represent only a minor hiccup in the patient’s care. I’ll even admit that sometimes the processes probably do catch cases of insurance fraud. But what they actually do much of the time is block the patient from receiving the care that both they and their doctors believe is necessary, at least until seemingly arbitrary and intentionally onerous hoops are jumped through first.
This story is a real life example (of course names have been omitted and a few details have been changed), and I know this because I was involved in this case, though I don’t enter in within this part of the narrative. But as illustrative of the problem as this case is, any doctor you know could provide a dozen or a hundred other examples at the drop of a hat. If you live in the American medical system, if you have a medical emergency or a catastrophic diagnosis, of course you are going to be thankful that you have insurance, and the better your insurance the more grateful you will be (though even this might not protect you from incurring astronomic medical debts). But ultimately, unlike your doctor or nurse or physical therapist who chose their profession because they wanted a vocation that allowed them to make a living while helping others, these companies exist to make a profit, to take in more money from insured people’s premiums than they pay out in claims or expenses; and we forget that, and think of them as real allies in healthcare, only at our peril.
A 2 year old little girl fell and broke her arm. It happened while playing outside in the evening, and when she wasn’t able to move it without excruciating pain, her family went to the Emergency Room at their local hospital. They chose that hospital, out of all the hospitals in town, because it was owned and operated by the same company through which they have their medical insurance (this is important). The child was found to have a fairly rare and complex fracture, and it was intra-articular; it was affecting the bone at the elbow joint. This always makes for a more complex and unstable fracture, with greater risk for poor or dysfunctional healing and long term sequelae. Fortunately, the hand and arm beyond the fracture had good blood flow and sensation, and the fracture didn’t appear to be displaced. The Emergency Room doctor and nurses splinted the arm to keep the joint stable, but didn’t have a pediatric Orthopedic surgeon on call; since it was a weekday, however, they made a referral to a surgeon within their system for the child to be seen the following day. The appointment was scheduled and the child went home with her family.
So far, except for the actual breaking the arm part, everything had gone smoothly. And it just happened to be in a neat little package; the Emergency Room, the x-ray machine and radiology tech, the ER doc, the nurses, and the Pediatric Orthopedic surgeon, his clinic, the nurses he works with, and the OR he operates in were all under the umbrella of the very same company that provides the patient’s insurance. This, surely, is how these systems are supposed to work, right? Scenarios like this are exactly why this family, or your family, would prefer to have private insurance instead of, say, Medicaid. All that needed to happen now was for the patient to be seen the next day (Friday) by the Orthopedic surgeon, for that surgeon and the parents to decide on a course of action, and then either cast the arm or schedule surgery, or both.
That’s what should have happened, but because of policies that insurance company had in place to slow down utilization and save money, here’s what happened instead. The family called the Orthopedic Surgeon’s office the following morning, bright and early, to confirm the appointment time; they were told that without a referral she couldn’t be seen. They explained that they had a referral from the day before, but this insurance company’s policy is that the referral has to come from the Primary Care Doctor, not from the ER; it is part of their prior authorization process. If the patient were seen without that referral, the insurance wouldn’t pay for the visit and the full cost of it would be on the patient; since sometimes patients don’t pay their medical bills, the Ortho clinic wouldn’t schedule the visit until they received (and processed) the referral. The family had no other choice; they scheduled an appointment with their Pediatrician, who works in a totally different healthcare system, just to get that referral.
Now, if the family had known they had this option, they could have called their Pediatrician and explained the situation, and she would have sent the referral right away without an appointment, and then spent the morning advocating for her to be seen that very afternoon even before the referral had been ‘processed’, eventually either sweet-talking or strong-arming the clinic’s front desk into getting her on the schedule, or failing that, going over their heads and asking the surgeon directly (who despite all the stereotypes typically have strong feelings about not ignoring little girls’ broken arms); as primary care physicians we have to do that kind of thing all the time. The family didn’t know this, however, so they schedule an appointment for that afternoon with the Pediatrician; it felt like the best they could do.
So just after 4 PM on Friday afternoon, after seeing who knows how many patients that day already, the Pediatrician has this little girl walk into her office and she discovers the situation they are facing. It’s far too late to get them in to see the Orthopedic Surgeon that afternoon, even if they could get them on the schedule (they couldn’t), and even if the clinic were only across town (it wasn’t). The Pediatrician asks her nurses to call the Ortho clinic while she researches more about the type of fracture she has, which is very rare in a child this age. Every case study she can find tells her that the break will need surgical fixation; but some have it being done immediately and others have it casted for 2 weeks first, and the Pediatrician simply doesn’t have the Ortho background to know which is best in her case. Her plan is to ask the Pedi Orthopedist to look at the x-rays and give them an opinion; can the child wait to be seen Monday morning, or does she need to send her to the ED in another town where the Orthopedist consults, so they can treat her that evening?
The nurses get in touch with the front desk at the Ortho Clinic, and they actually tell the team that the Pediatrician can’t talk to the Orthopedist about this patient until they receive the referral (which the medical assistant was faxing at that very moment); the nurse transfers the call to the Pediatrician and she ‘pulls rank’, something we Primary Care Doctors rarely do (and even more rarely succeed at); they page the surgeon, and the Pediatrician waits on hold. Eventually they let her know that they will keep trying and will pass along the message, and she gives them her cell phone number. Despite having other patients to see and being behind on charts that afternoon already, she has a long discussion with the family about the plan, and the contingency plans, and the backup contingency plans, all revolving around what the surgeon says and if they are even able to get through to anyone with the Ortho team in the first place.
-At 4:45 she hasn’t heard anything, so she calls again.
-At 5 she lets the family know she is still waiting on hold, but they can go home and she will call them as soon as she hears from Ortho; she makes sure the mom’s number is correct in the computer system so she can reach her.
-At 5:15 she gets in touch with Ortho; with the resident on call, I believe. He takes the medical record number and date of birth, and the Pediatrician’s cell number; he isn’t is a place where he can look at the x-ray right now but will call her back.
-At 6:30 she still hasn’t heard back (and didn’t think to get his cell phone number, she later realizes), so she calls the mom and lets them know she is still waiting. The child is doing well and they have bags packed in case they need to go to the ED to get seen by Ortho that night, which is one of the possible plans they discussed.
-Also at 6:30, the Pediatrician takes her kids to a local park. Even though she is not on call, she checks her phone about every 5 minutes to make sure she hasn’t missed a call from Ortho. She doesn’t.
-At 8:30 she is back home, and her partner gets to put the kids to bed alone while she sits on the phone, on hold again waiting for Ortho. She spends her time reading every case study she can about this type of fracture; she is increasingly unconvinced that it can safely wait until Monday to be addressed.
-At 9 PM she hangs up and calls the mom instead (at that point you are reaching the unprofessional hours of the night, and as silly as it seems a lot of doctors feel like they are leaving the wrong impression by calling past 9 or 10 PM); she apologizes profusely that she hadn’t been able to reach Ortho and advises her to go to the ED in the other town where they can get Pedi Ortho to look at her arm. Hopefully that ED trip will end up being ultimately unnecessary, she says, and the surgeon will look at her arm and get new x-rays and tell her to come back to clinic on Monday after all (now that she at least has a referral in place)…. But if not, if they do think she needs surgery right away, it will have been worth it. This is an exercise in frustration, but it’s what she would do if it were her kid and she couldn’t get an expert opinion in any other way.
-At 9:10 PM Ortho calls her back in response to that second round of calls; an older doc this time, probably the attending. She tells him the story and he is motivated to help this kid, as most doctors almost always are. He pulls up the x-rays and they aren’t showing him what he needs to see; he asks if she can get new x-rays at different angles (naturally assuming she is at an ER or Urgent Care facility because of the hour). She explains that she is in her living room, and the patient is in her living room, and neither living room has an x-ray machine (the snarkiness is my own addition). He wants to run the x-rays by a colleague; he will call her back. She calls mom and lets her know to pump the breaks on driving to the other ER, which I should mention at this point is over an hour away.
-At 9:20 the surgeon calls back. They agree the fracture shouldn’t wait until Monday, and they need additional x-rays to come up with a specific plan. But, realistically they aren’t going to do anything about it at midnight tonight anyway, especially with it already in a cast. They recommend letting the family sleep at home and then heading to the ER first thing in the morning; he is going to notify the ER doc and the Orthopedist on call the following day to make sure everything that is suppose to happen, does happen.
-At 9:25 The Pediatrician calls mom again and explains everything about the plan in detail, and reassures her that now there is solid Orthopedic surgical advice behind the recommendation; mom is comfortable with the plan and is ready to drive to the ER tomorrow morning. The child is resting comfortably after taking some pain medicine, but still not moving her arm. The Pediatrician finishes the visit note on the computer, then goes back to her other lingering clinic work, and eventually goes to bed. She would have clinic work to catch-up on the next day (Saturday), of course; but that’s the natural penalty for 1. taking the extra time to coordinate care for this patient, and 2. daring to spend a few hours with her kids on a Friday evening.
Saturday morning the family arrived at the ER promptly, and after a little confusion and a few explanations, everyone realized this was the child the Orthopedic surgeon and ER doc had been talking about last night. Ortho was paged, she had her new x-rays done, and had surgery on Sunday to fix the fracture.
From Wikipedia: “Insurers have stated that the purpose of prior authorization checks is to provide cost savings to consumers by preventing unnecessary procedures as well as the prescribing of expensive brand name drugs when an appropriate generic is available.”
So to sum up, this Pediatrician spent well over 2 hours on the phone over the course of an entire evening, coordinating care between two hospitals, her clinic, and two Orthopedic surgeons, in order to facilitate weekend, emergency room based specialist care for a little girl with a broken arm… who should have just been seen in Ortho clinic on Friday instead of seeing her Pediatrician in the first place. (By the way, the doctor in question billed this to her insurance at the level of a 25 minute visit; we don’t really get to bill for our full time the way lawyers do).
Why? Because this healthcare system’s policy is to not trust an ER doctor that they employ to know that the patient needed to see an Orthopedic surgeon they also employ, and instead require a referral from the PCP. Because that policy slows down the delivery of care and, in aggregate, means they have to pay for fewer specialist visits, and that means they get to keep more money from insurance premiums as profits; or in their words, “cost savings to consumers.”