Guest guest Posted June 9, 2012 Report Share Posted June 9, 2012 To: Sent: Sat, June 9, 2012 2:41:36 PMSubject: Why PAs? Please send one green at your earliest convenience.Of course, many prior authorizations are a ridiculous waste of time and energy, but I am an advocate of rational PAs. Too many doctors wantonly order inappropriate tests and medications. Physicians bias toward errors of commission and fear of making errors of omission leading to malpractice suits, is part of the reason that Americans pay a higher percentage of our gross domestic product than any nation yet we lag in quality measures across the board.Choosing Wisely is an effort of nine medical societies representing 375,000 physicians to encourage physicians to be better stewards of finite health care resources. In order to improve care we need to eliminate unnecessary tests and procedures. Too often well meaning doctors order tests that do not improve outcomes. A few examples:a) Early imaging for back pain, which would resolve in a few weeks. CT or MRI in patients with syncope and normal neurological exams.c) Pre-operative chest x-rays in patients without clinical suspicion of pathology.A member of a local Pharmacy and Therapeutics Committee of Neighborhood Health Plan of Rhode Island, I am proud of a recent action. Two years ago we altered our Suboxone PA prohibiting off label use- some physicians were ordering it to treat pain. Over the past year NHPRI providers requested PAs for Suboxone more than any other medication. Our review showed that all PAs were approved. Our solution? We eliminated the prior authorization, thus saving valuable physician and pharmacist time and energy.Any limitation of physician prerogative needs be rational. In the zero sum game of American Medicine, physicians practice will be subjected to constraints as long as many physicians fail to adhere to best practices based on sound science. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 I thought about replying to 's comment.Then I remembered the saying, "If you can't say something nice, don't say anything at all"...RhondaTo: Sent: Sat, June 9, 2012 2:55:46 PMSubject: Re: Why PAs? To: Sent: Sat, June 9, 2012 2:41:36 PMSubject: Why PAs? Please send one green at your earliest convenience.Of course, many prior authorizations are a ridiculous waste of time and energy, but I am an advocate of rational PAs. Too many doctors wantonly order inappropriate tests and medications. Physicians bias toward errors of commission and fear of making errors of omission leading to malpractice suits, is part of the reason that Americans pay a higher percentage of our gross domestic product than any nation yet we lag in quality measures across the board.Choosing Wisely is an effort of nine medical societies representing 375,000 physicians to encourage physicians to be better stewards of finite health care resources. In order to improve care we need to eliminate unnecessary tests and procedures. Too often well meaning doctors order tests that do not improve outcomes. A few examples:a) Early imaging for back pain, which would resolve in a few weeks. CT or MRI in patients with syncope and normal neurological exams.c) Pre-operative chest x-rays in patients without clinical suspicion of pathology.A member of a local Pharmacy and Therapeutics Committee of Neighborhood Health Plan of Rhode Island, I am proud of a recent action. Two years ago we altered our Suboxone PA prohibiting off label use- some physicians were ordering it to treat pain. Over the past year NHPRI providers requested PAs for Suboxone more than any other medication. Our review showed that all PAs were approved. Our solution? We eliminated the prior authorization, thus saving valuable physician and pharmacist time and energy.Any limitation of physician prerogative needs be rational. In the zero sum game of American Medicine, physicians practice will be subjected to constraints as long as many physicians fail to adhere to best practices based on sound science. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 " I am an advocate of rational PAs " who determines that word -- 'rational' --- the doctor? the insurance company? some governing board of god knows what? the hospital ceo? the emergency room? mr. attorney,jd? the patient? or disease? grace > > Please send one green at your earliest convenience. > > Of course, many prior authorizations are a ridiculous waste of time and energy, but I am an advocate of rational PAs. Too many doctors wantonly order inappropriate tests and medications. Physicians bias toward errors of commission and fear of making errors of omission leading to malpractice suits, is part of the reason that Americans pay a higher percentage of our gross domestic product than any nation yet we lag in quality measures across the board. > > Choosing Wisely is an effort of nine medical societies representing 375,000 physicians to encourage physicians to be better stewards of finite health care resources. In order > to improve care we need to eliminate unnecessary tests and procedures. Too often well meaning doctors order tests that do not improve outcomes. A few examples: > a) Early imaging for back pain, which would resolve in a few weeks. > CT or MRI in patients with syncope and normal neurological exams. > c) Pre-operative chest x-rays in patients without clinical suspicion of pathology. > > A member of a local Pharmacy and Therapeutics Committee of Neighborhood Health Plan of Rhode Island, I am proud of a recent action. Two years ago we altered our Suboxone PA prohibiting off label use- some physicians were ordering it to treat pain. Over the past year NHPRI providers requested PAs for Suboxone more than any other medication. Our review showed that all PAs were approved. Our solution? We eliminated the prior authorization, thus saving valuable physician and pharmacist time and energy. > > Any limitation of physician prerogative needs be rational. In the zero sum game of American Medicine, physicians practice will be subjected to constraints as long as many physicians fail to adhere to best practices based on sound science. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 A couple of years after I opened my practice, BCBS in our area decided that every CT needed prior authorization. We could do the prior auth on line and get a response in a day or two or we could go through the phone tree and try and get it approved in about 30 minutes or so. One day my nurse was gone and I had a patient with RLQ abdominal pain. He was a healthy guy who was generally pretty stoic. I was worried about an appendix, but knew it would take 30 minutes to get the test approved. My schedule was light so I decided to call for the approval. After a horrible process where the nurse was initially reticent to give me the approval, the CT was done and it showed a ruptured appendix. Scary. I called the person in charge of prior auths for BCBS mid-Atlantic and fussed a bit and then listened for a while and these were the conclusions I have come away with:1) The purpose of prior auths is to increase barriers to care and therefore decrease the ordering of the test/medication (provider abrasion) in order to decrease costs.2) The insurance companies historically do not have the technology (or perhaps the willpower) to separate out the high utilizers of testing from the rest and so they force everyone to go through these procedures regardless if you order a CT scan every day or one a year.3) The use of prior auths not only increases administrative liability for the office (i.e. hours of uncompensated work), but it can also increase clinical liability (see example above). As clinicians, we make decisions in the blink of an eye, and yes, if faced with enough provider abrasion, we will not order the necessary diagnostic test. The problem is that if the test was not ordered, it is our fault not the insurance company’s. After all, the insurance company will claim that they never said not to do the test, they just said they would not pay for it.4) Increasing prior auths shifts costs in other ways. In the above scenario, many docs would send the patient to the ER. In this case that is appropriate, but some docs are now sending every patient needing a CT to the ER so they do not have to deal with provider abrasion. Though this would keep the office cost low, overall health care costs soar. But, these costs are not recognized because they are noted as ER costs and not primary care costs.5) Even outside the realm of sending patients to the ER, the abrasion is so abrasive to many primary care docs that they decide to retire or leave medicine all together. This administrative “straw that breaks the camel’s back” results in fewer primary care docs and therefore increase costs.6) Ultimately, prior auths fail to contain costs. Not only do docs start sending their patients to the ER to get CTs or leave practice altogether, but sooner or later every doctor’s office learns what needs to be said in order to get the approval done. So the entire process is one of semantics. Once the correct words are known, those will be used over and over again and the “abrasion” is minimized and utilization increases again. (Note: though I am talking radiology prior auths, the same can be said for prescriptions).Yes, there are docs out there who are prescribing too many name brand drugs, or prescribing inappropriately, or ordering way too many tests. Those docs need to be identified and educated to the fact that they are outliers. However, erecting barriers to care which drive a wedge between doctors and their patients is not the right solution. Prior auths increase office administrative costs, increase clinical liability, decrease provider satisfaction, and if evaluated critically, probably do not even work to decrease overall costs. Better ways of encouraging good behavior (instead of punishing “bad”) need to be brought to the forefront. From: [mailto: ] On Behalf Of MachataSent: Saturday, June 09, 2012 5:42 PMTo: Subject: Why PAs? Please send one green at your earliest convenience.Of course, many prior authorizations are a ridiculous waste of time and energy, but I am an advocate of rational PAs. Too many doctors wantonly order inappropriate tests and medications. Physicians bias toward errors of commission and fear of making errors of omission leading to malpractice suits, is part of the reason that Americans pay a higher percentage of our gross domestic product than any nation yet we lag in quality measures across the board.Choosing Wisely is an effort of nine medical societies representing 375,000 physicians to encourage physicians to be better stewards of finite health care resources. In order to improve care we need to eliminate unnecessary tests and procedures. Too often well meaning doctors order tests that do not improve outcomes. A few examples:a) Early imaging for back pain, which would resolve in a few weeks. CT or MRI in patients with syncope and normal neurological exams.c) Pre-operative chest x-rays in patients without clinical suspicion of pathology.A member of a local Pharmacy and Therapeutics Committee of Neighborhood Health Plan of Rhode Island, I am proud of a recent action. Two years ago we altered our Suboxone PA prohibiting off label use- some physicians were ordering it to treat pain. Over the past year NHPRI providers requested PAs for Suboxone more than any other medication. Our review showed that all PAs were approved. Our solution? We eliminated the prior authorization, thus saving valuable physician and pharmacist time and energy.Any limitation of physician prerogative needs be rational. In the zero sum game of American Medicine, physicians practice will be subjected to constraints as long as many physicians fail to adhere to best practices based on sound science. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 john, i should cut and paste and send your post to the media. this requires more attention than that $5 bill for a wait type of thing. as far as i know, you get the $20 but i believe i already gave that out. ill see if i can get another $20 to give you on monday... ill give you another $10 if you can tell me where to take it from here. bravo my friend. i hope you are a governing board member of somewhere and you can push this so it will make a difference. ill just hang on to your coattail for now. im far too exhausted and angry with all these. g > > A couple of years after I opened my practice, BCBS in our area decided that > every CT needed prior authorization. We could do the prior auth on line and > get a response in a day or two or we could go through the phone tree and try > and get it approved in about 30 minutes or so. One day my nurse was gone and > I had a patient with RLQ abdominal pain. He was a healthy guy who was > generally pretty stoic. I was worried about an appendix, but knew it would > take 30 minutes to get the test approved. My schedule was light so I decided > to call for the approval. After a horrible process where the nurse was > initially reticent to give me the approval, the CT was done and it showed a > ruptured appendix. Scary. I called the person in charge of prior auths for > BCBS mid-Atlantic and fussed a bit and then listened for a while and these > were the conclusions I have come away with: > > 1) The purpose of prior auths is to increase barriers to care and > therefore decrease the ordering of the test/medication (provider abrasion) > in order to decrease costs. > > 2) The insurance companies historically do not have the technology (or > perhaps the willpower) to separate out the high utilizers of testing from > the rest and so they force everyone to go through these procedures > regardless if you order a CT scan every day or one a year. > > 3) The use of prior auths not only increases administrative liability > for the office (i.e. hours of uncompensated work), but it can also increase > clinical liability (see example above). As clinicians, we make decisions in > the blink of an eye, and yes, if faced with enough provider abrasion, we > will not order the necessary diagnostic test. The problem is that if the > test was not ordered, it is our fault not the insurance company's. After > all, the insurance company will claim that they never said not to do the > test, they just said they would not pay for it. > > 4) Increasing prior auths shifts costs in other ways. In the above > scenario, many docs would send the patient to the ER. In this case that is > appropriate, but some docs are now sending every patient needing a CT to the > ER so they do not have to deal with provider abrasion. Though this would > keep the office cost low, overall health care costs soar. But, these costs > are not recognized because they are noted as ER costs and not primary care > costs. > > 5) Even outside the realm of sending patients to the ER, the abrasion > is so abrasive to many primary care docs that they decide to retire or leave > medicine all together. This administrative " straw that breaks the camel's > back " results in fewer primary care docs and therefore increase costs. > > 6) Ultimately, prior auths fail to contain costs. Not only do docs > start sending their patients to the ER to get CTs or leave practice > altogether, but sooner or later every doctor's office learns what needs to > be said in order to get the approval done. So the entire process is one of > semantics. Once the correct words are known, those will be used over and > over again and the " abrasion " is minimized and utilization increases again. > (Note: though I am talking radiology prior auths, the same can be said for > prescriptions). > > Yes, there are docs out there who are prescribing too many name brand drugs, > or prescribing inappropriately, or ordering way too many tests. Those docs > need to be identified and educated to the fact that they are outliers. > However, erecting barriers to care which drive a wedge between doctors and > their patients is not the right solution. Prior auths increase office > administrative costs, increase clinical liability, decrease provider > satisfaction, and if evaluated critically, probably do not even work to > decrease overall costs. Better ways of encouraging good behavior (instead of > punishing " bad " ) need to be brought to the forefront. > > > > > > From: > [mailto: ] On Behalf Of Machata > Sent: Saturday, June 09, 2012 5:42 PM > To: > Subject: Why PAs? > > > > > > > Please send one green at your earliest convenience. > > Of course, many prior authorizations are a ridiculous waste of time and > energy, but I am an advocate of rational PAs. Too many doctors wantonly > order inappropriate tests and medications. Physicians bias toward errors of > commission and fear of making errors of omission leading to malpractice > suits, is part of the reason that Americans pay a higher percentage of our > gross domestic product than any nation yet we lag in quality measures across > the board. > > Choosing Wisely is an effort of nine medical societies representing 375,000 > physicians to encourage physicians to be better stewards of finite health > care resources. In order to improve care we need to eliminate unnecessary > tests and procedures. Too often well meaning doctors order tests that do not > improve outcomes. A few examples: > a) Early imaging for back pain, which would resolve in a few weeks. > CT or MRI in patients with syncope and normal neurological exams. > c) Pre-operative chest x-rays in patients without clinical suspicion of > pathology. > > A member of a local Pharmacy and Therapeutics Committee of Neighborhood > Health Plan of Rhode Island, I am proud of a recent action. Two years ago we > altered our Suboxone PA prohibiting off label use- some physicians were > ordering it to treat pain. Over the past year NHPRI providers requested PAs > for Suboxone more than any other medication. Our review showed that all PAs > were approved. Our solution? We eliminated the prior authorization, thus > saving valuable physician and pharmacist time and energy. > > Any limitation of physician prerogative needs be rational. In the zero sum > game of American Medicine, physicians practice will be subjected to > constraints as long as many physicians fail to adhere to best practices > based on sound science. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 SCENARIO 1 : Prior authorization of bupropion SR. Already generic. 1877****** ....bryan adams, bruno mars, rain and birds chirping in background,bruce springsteen and born in the usa. ....18 minutes ....all our agents are busy ....3 minutes ....this call will be recorded (for my expletives probably) hello this is blah blah whats your patient's name, member number, date of birth whats your name, confirm your address, telefone (in case i hung up) what is this prescription for? Is BUP-PION used for the treatment of smoking? No. I'm sorry I didnt hear you. I said No. Ok. If BUP-pion is not used for treatment of smoking, we are authorizing this prescription until May 2013. Is there anything I... I hung up. Provider abrasion all 27 minutes. I could have seen a few patients for this time, saved a life or probably had used this time to eat my lunch. g Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 We can talk about prior authorizations all we want. But the real problem is to third-party system and why doctors continue to put up with this abuse. Please don't come back with well that's the way it is and we have to accept it. Know that it's not the way it is. We have let it happen and we can change it. Steve stown > > A couple of years after I opened my practice, BCBS in our area decided that > every CT needed prior authorization. We could do the prior auth on line and > get a response in a day or two or we could go through the phone tree and try > and get it approved in about 30 minutes or so. One day my nurse was gone and > I had a patient with RLQ abdominal pain. He was a healthy guy who was > generally pretty stoic. I was worried about an appendix, but knew it would > take 30 minutes to get the test approved. My schedule was light so I decided > to call for the approval. After a horrible process where the nurse was > initially reticent to give me the approval, the CT was done and it showed a > ruptured appendix. Scary. I called the person in charge of prior auths for > BCBS mid-Atlantic and fussed a bit and then listened for a while and these > were the conclusions I have come away with: > > 1) The purpose of prior auths is to increase barriers to care and > therefore decrease the ordering of the test/medication (provider abrasion) > in order to decrease costs. > > 2) The insurance companies historically do not have the technology (or > perhaps the willpower) to separate out the high utilizers of testing from > the rest and so they force everyone to go through these procedures > regardless if you order a CT scan every day or one a year. > > 3) The use of prior auths not only increases administrative liability > for the office (i.e. hours of uncompensated work), but it can also increase > clinical liability (see example above). As clinicians, we make decisions in > the blink of an eye, and yes, if faced with enough provider abrasion, we > will not order the necessary diagnostic test. The problem is that if the > test was not ordered, it is our fault not the insurance company's. After > all, the insurance company will claim that they never said not to do the > test, they just said they would not pay for it. > > 4) Increasing prior auths shifts costs in other ways. In the above > scenario, many docs would send the patient to the ER. In this case that is > appropriate, but some docs are now sending every patient needing a CT to the > ER so they do not have to deal with provider abrasion. Though this would > keep the office cost low, overall health care costs soar. But, these costs > are not recognized because they are noted as ER costs and not primary care > costs. > > 5) Even outside the realm of sending patients to the ER, the abrasion > is so abrasive to many primary care docs that they decide to retire or leave > medicine all together. This administrative " straw that breaks the camel's > back " results in fewer primary care docs and therefore increase costs. > > 6) Ultimately, prior auths fail to contain costs. Not only do docs > start sending their patients to the ER to get CTs or leave practice > altogether, but sooner or later every doctor's office learns what needs to > be said in order to get the approval done. So the entire process is one of > semantics. Once the correct words are known, those will be used over and > over again and the " abrasion " is minimized and utilization increases again. > (Note: though I am talking radiology prior auths, the same can be said for > prescriptions). > > Yes, there are docs out there who are prescribing too many name brand drugs, > or prescribing inappropriately, or ordering way too many tests. Those docs > need to be identified and educated to the fact that they are outliers. > However, erecting barriers to care which drive a wedge between doctors and > their patients is not the right solution. Prior auths increase office > administrative costs, increase clinical liability, decrease provider > satisfaction, and if evaluated critically, probably do not even work to > decrease overall costs. Better ways of encouraging good behavior (instead of > punishing " bad " ) need to be brought to the forefront. > > > > > > From: > [mailto: ] On Behalf Of Machata > Sent: Saturday, June 09, 2012 5:42 PM > To: > Subject: Why PAs? > > > > > > > Please send one green at your earliest convenience. > > Of course, many prior authorizations are a ridiculous waste of time and > energy, but I am an advocate of rational PAs. Too many doctors wantonly > order inappropriate tests and medications. Physicians bias toward errors of > commission and fear of making errors of omission leading to malpractice > suits, is part of the reason that Americans pay a higher percentage of our > gross domestic product than any nation yet we lag in quality measures across > the board. > > Choosing Wisely is an effort of nine medical societies representing 375,000 > physicians to encourage physicians to be better stewards of finite health > care resources. In order to improve care we need to eliminate unnecessary > tests and procedures. Too often well meaning doctors order tests that do not > improve outcomes. A few examples: > a) Early imaging for back pain, which would resolve in a few weeks. > CT or MRI in patients with syncope and normal neurological exams. > c) Pre-operative chest x-rays in patients without clinical suspicion of > pathology. > > A member of a local Pharmacy and Therapeutics Committee of Neighborhood > Health Plan of Rhode Island, I am proud of a recent action. Two years ago we > altered our Suboxone PA prohibiting off label use- some physicians were > ordering it to treat pain. Over the past year NHPRI providers requested PAs > for Suboxone more than any other medication. Our review showed that all PAs > were approved. Our solution? We eliminated the prior authorization, thus > saving valuable physician and pharmacist time and energy. > > Any limitation of physician prerogative needs be rational. In the zero sum > game of American Medicine, physicians practice will be subjected to > constraints as long as many physicians fail to adhere to best practices > based on sound science. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 dr.horvitz. true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist. but harping on 'not accepting third party payers' doesnt really solve the issue. example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on. so have you not dealt with prior authorizations at all, so what do your patients do? " here is this ct scan i need you to do, call your insurance company? " if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through? my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody. grace Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 I agree with all 's points except #2. "2) The insurance companies historically do not have the technology (orperhaps the willpower) to separate out the high utilizers of testing fromthe rest and so they force everyone to go through these proceduresregardless if you order a CT scan every day or one a year. " The insurance companies have the technology to identify the high utilizers. For many years, I was consistently given annual reports stating my costs for patient care were below average, and my outcomes, preventative measures, etc were above average. Yet, despite my requests to be "gold carded" , I have to go thru the same prior auth as everyone else. It is not that they lack the willpower either. The goal, as you say, is to increase provider abrasion for all of us and not just the "overutilizers". A buck saved is still a buck saved. Mike Safran Re: Why PAs?Posted by: "Dr. Brady" drbrady@... famdocman3Sat Jun 9, 2012 7:38 pm (PDT) A couple of years after I opened my practice, BCBS in our area decided thatevery CT needed prior authorization. We could do the prior auth on line andget a response in a day or two or we could go through the phone tree and tryand get it approved in about 30 minutes or so. One day my nurse was gone andI had a patient with RLQ abdominal pain. He was a healthy guy who wasgenerally pretty stoic. I was worried about an appendix, but knew it wouldtake 30 minutes to get the test approved. My schedule was light so I decidedto call for the approval. After a horrible process where the nurse wasinitially reticent to give me the approval, the CT was done and it showed aruptured appendix. Scary. I called the person in charge of prior auths forBCBS mid-Atlantic and fussed a bit and then listened for a while and thesewere the conclusions I have come away with:1) The purpose of prior auths is to increase barriers to care andtherefore decrease the ordering of the test/medication (provider abrasion)in order to decrease costs.2) The insurance companies historically do not have the technology (orperhaps the willpower) to separate out the high utilizers of testing fromthe rest and so they force everyone to go through these proceduresregardless if you order a CT scan every day or one a year.3) The use of prior auths not only increases administrative liabilityfor the office (i.e. hours of uncompensated work), but it can also increaseclinical liability (see example above). As clinicians, we make decisions inthe blink of an eye, and yes, if faced with enough provider abrasion, wewill not order the necessary diagnostic test. The problem is that if thetest was not ordered, it is our fault not the insurance company's. Afterall, the insurance company will claim that they never said not to do thetest, they just said they would not pay for it.4) Increasing prior auths shifts costs in other ways. In the abovescenario, many docs would send the patient to the ER. In this case that isappropriate, but some docs are now sending every patient needing a CT to theER so they do not have to deal with provider abrasion. Though this wouldkeep the office cost low, overall health care costs soar. But, these costsare not recognized because they are noted as ER costs and not primary carecosts.5) Even outside the realm of sending patients to the ER, the abrasionis so abrasive to many primary care docs that they decide to retire or leavemedicine all together. This administrative "straw that breaks the camel'sback" results in fewer primary care docs and therefore increase costs.6) Ultimately, prior auths fail to contain costs. Not only do docsstart sending their patients to the ER to get CTs or leave practicealtogether, but sooner or later every doctor's office learns what needs tobe said in order to get the approval done. So the entire process is one ofsemantics. Once the correct words are known, those will be used over andover again and the "abrasion" is minimized and utilization increases again.(Note: though I am talking radiology prior auths, the same can be said forprescriptions).Yes, there are docs out there who are prescribing too many name brand drugs,or prescribing inappropriately, or ordering way too many tests. Those docsneed to be identified and educated to the fact that they are outliers.However, erecting barriers to care which drive a wedge between doctors andtheir patients is not the right solution. Prior auths increase officeadministrative costs, increase clinical liability, decrease providersatisfaction, and if evaluated critically, probably do not even work todecrease overall costs. Better ways of encouraging good behavior (instead ofpunishing "bad") need to be brought to the forefront. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 My Blue Cross gives some docs exemptions from PA of CTs, but you have to order a certain number of them per year before they will consider whether your percentage is low enough. My requests are ALL approved, but I don't order enough to qualify. Go figure!---Sharlene > > > ** > > > > > > I agree with all 's points except #2. > > > > * " 2) The insurance companies historically do not have the technology (or > > perhaps the willpower) to separate out the high utilizers of testing from > > the rest and so they force everyone to go through these procedures > > regardless if you order a CT scan every day or one a year. " * > > > > The insurance companies have the technology to identify the high > > utilizers. For many years, I was consistently given annual reports > > stating my costs for patient care were below average, and my outcomes, > > preventative measures, etc were above average. Yet, despite my requests > > to be " gold carded " , I have to go thru the same prior auth as everyone > > else. > > > > It is not that they lack the willpower either. The goal, as you say, is > > to increase provider abrasion for all of us and not just the > > " overutilizers " . A buck saved is still a buck saved. > > > > Mike Safran > > > > Re: Why PAs?<http://groups.yahoo.com/group//message/59764;_ylc=X3oDM\ TJybDZ2bm43BF9TAzk3MzU5NzE1BGdycElkAzkzNjA5MTQEZ3Jwc3BJZAMxNzA1MDYxMzI3BG1zZ0lkA\ zU5NzY0BHNlYwNkbXNnBHNsawN2bXNnBHN0aW1lAzEzMzkzNDIzMDc-> Posted > > by: " Dr. Brady " drbrady@... <drbrady@...?Subject=%20Re%3A%20Why%20PAs%3F> > > famdocman3 <http://profiles.yahoo.com/famdocman3> Sat Jun 9, 2012 > > 7:38 pm (PDT) > > > > > > A couple of years after I opened my practice, BCBS in our area decided that > > every CT needed prior authorization. We could do the prior auth on line and > > get a response in a day or two or we could go through the phone tree and > > try > > and get it approved in about 30 minutes or so. One day my nurse was gone > > and > > I had a patient with RLQ abdominal pain. He was a healthy guy who was > > generally pretty stoic. I was worried about an appendix, but knew it would > > take 30 minutes to get the test approved. My schedule was light so I > > decided > > to call for the approval. After a horrible process where the nurse was > > initially reticent to give me the approval, the CT was done and it showed a > > ruptured appendix. Scary. I called the person in charge of prior auths for > > BCBS mid-Atlantic and fussed a bit and then listened for a while and these > > were the conclusions I have come away with: > > > > 1) The purpose of prior auths is to increase barriers to care and > > therefore decrease the ordering of the test/medication (provider abrasion) > > in order to decrease costs. > > > > 2) The insurance companies historically do not have the technology (or > > perhaps the willpower) to separate out the high utilizers of testing from > > the rest and so they force everyone to go through these procedures > > regardless if you order a CT scan every day or one a year. > > > > 3) The use of prior auths not only increases administrative liability > > for the office (i.e. hours of uncompensated work), but it can also increase > > clinical liability (see example above). As clinicians, we make decisions in > > the blink of an eye, and yes, if faced with enough provider abrasion, we > > will not order the necessary diagnostic test. The problem is that if the > > test was not ordered, it is our fault not the insurance company's. After > > all, the insurance company will claim that they never said not to do the > > test, they just said they would not pay for it. > > > > 4) Increasing prior auths shifts costs in other ways. In the above > > scenario, many docs would send the patient to the ER. In this case that is > > appropriate, but some docs are now sending every patient needing a CT to > > the > > ER so they do not have to deal with provider abrasion. Though this would > > keep the office cost low, overall health care costs soar. But, these costs > > are not recognized because they are noted as ER costs and not primary care > > costs. > > > > 5) Even outside the realm of sending patients to the ER, the abrasion > > is so abrasive to many primary care docs that they decide to retire or > > leave > > medicine all together. This administrative " straw that breaks the camel's > > back " results in fewer primary care docs and therefore increase costs. > > > > 6) Ultimately, prior auths fail to contain costs. Not only do docs > > start sending their patients to the ER to get CTs or leave practice > > altogether, but sooner or later every doctor's office learns what needs to > > be said in order to get the approval done. So the entire process is one of > > semantics. Once the correct words are known, those will be used over and > > over again and the " abrasion " is minimized and utilization increases again. > > (Note: though I am talking radiology prior auths, the same can be said for > > prescriptions)**. > > > > Yes, there are docs out there who are prescribing too many name brand > > drugs, > > or prescribing inappropriately, or ordering way too many tests. Those docs > > need to be identified and educated to the fact that they are outliers. > > However, erecting barriers to care which drive a wedge between doctors and > > their patients is not the right solution. Prior auths increase office > > administrative costs, increase clinical liability, decrease provider > > satisfaction, and if evaluated critically, probably do not even work to > > decrease overall costs. Better ways of encouraging good behavior (instead > > of > > punishing " bad " ) need to be brought to the forefront. > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 yes ive seen the letters.... my patients, the 'privileged' say why cant you call for me? this is when i give them the number after they push my MA who only does PA for me over the cliff. only then after i tell them i dont want to be on the fone for 40 minutes, do they quit yelling. i give them a chair and a timer when they call the PA number. and most of them are humbled... very very humbled. and yes after all these, i still have my soul. i sing it every morning. sadly, g > > Part of the problem is that the supreme court vilified the PA practice when > they said that patients couldn't sue insurers for refusing to cover a > service, medicine or test. They dumped it back in our laps by saying that > they weren't practicing medicine by the denials and that if the doctor still > thought the care item was necessary, then the patient could pay for it > themselves or the doctor could find an alternative. Thereby making us the > bad guy in the patients eyes. Then you have patients who don't understand > what a PA is and why it is needed and don't understand why you have > prescribed a different medicine or procedure when their insurance is sending > them letters telling them that what you have prescribed is going to cost > them a lot of money or that there is a test that can be done that is > cheaper. > > > > Have any of you ever read the letters sent to patients? Most of them are > very degrading to health care providers (us) and make us out to be the bad > guy. As long as this type of undermining is allowed to exist, the problem > of PA's and all the other 3rd party interference will continue. > > > > Dr. Beth Sullivan, DO > > > > From: > [mailto: ] On Behalf Of pricklyfinger2007 > Sent: Sunday, June 10, 2012 2:33 PM > To: > Subject: Re: Why PAs? > > > > > > dr.horvitz. > > true that. i didnt sign up for primary care to be canonized and i certainly > should make it clear im not a masochist. > > but harping on 'not accepting third party payers' doesnt really solve the > issue. > > example, the example i just gave. there is not a single reason that generic > meds need to be prior authorized. escitalopram over fluoxetine or > citalopram, to the extent that insurers dictate what patients should be on. > > so have you not dealt with prior authorizations at all, so what do your > patients do? " here is this ct scan i need you to do, call your insurance > company? " if I have difficulty in finding the right answers to give the > almighty PA person to get an rx or test done, what do our patients have to > go through? > > my laments: it's very clear. dr. brady has outlined very clearly what the > problem is, but even then, it is not clear to everybody. > > grace > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.