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Monday Mar 05, 2018

Jumping Through Hoops Wastes My Time, Worsens Outcomes

Every day, I get denial notifications for tests or treatments I've ordered. I can't remember the last time an entire day passed without something I thought a patient needed being denied. Often, these are treatments that, if delayed, might result in bad outcomes or hospitalizations, the very things insurance companies say they want to avoid. But in my experience, and through conversations with other primary care physicians, it doesn't feel like the insurance companies are truly committed to avoiding emergency visits and hospital admissions.

[denied in red letters with exclamation point]

It's hard enough to survive a day in a busy primary care office when the orders I place go smoothly. But my stress and frustration build to intolerable levels as each order I place bounces back due to insurance denial. I joke that sometimes I feel like I'm on that Ashton Kutcher show Punk'd because some of the denials for prior authorization requests are so ridiculous.

Even as I started to ponder writing this post, I heard pushback. People who don't practice medicine suggested that maybe I'm doing something wrong. Maybe I'm not using the right criteria for ordering tests, or maybe I'm using the wrong diagnosis codes. But every one of you in outpatient primary care knows this reality, and you likely have seen it increase in the past two months.

The concept of first-line treatment -- that is, using the medication that is most appropriate for the patient, is solidly evidence-based and is most likely to treat a condition with the least adverse effects -- is evidently not something insurance companies consider when crafting their formularies. No first-line treatment in well-established medical literature should require a prior authorization, and such treatments certainly should not be completely ruled out as options. Yet it happens every time a patient presents with an acute deep venous thrombosis or pulmonary embolism.

Last week, I ordered a six-month followup MRI to monitor growth of a known brain mass. The lab value associated with that mass was trending upward, the symptoms caused by the mass were worsening, and the plan from the entire team of doctors caring for this patient (family medicine, endocrinology, neurosurgery and ophthalmology) agreed on the six-month followup.



Denied again.

Now the patient will have to first see one of the subspecialists, who will then order the MRI, which will hopefully then be approved. Then the patient will have to reschedule the followup visit with that subspecialist, instead of having the MRI data before seeing the whole team. Meanwhile, the patient becomes more debilitated.

Influenza has been terrible this year, and I have had the antiemetics ondansetron (Zofran) and promethazine (Phenergan) denied without a prior authorization. Diagnosis codes used: vomiting, dehydration and influenza.

The absurd prior authorization process has previously been featured in this blog, and it is by far one of the more frustrating and unproductive things we deal with as physicians. Typically, we get a prior authorization request, we submit all the information the insurance company requests, then the payer gets what, in my opinion, is an unacceptable window of time to think about its next move -- somewhere between 24 hours and five days, depending on the company. This is how patients end up in the ER for IV fluids.

On Jan. 1 each year, many payers change their preferred inhaler, insulin and glucometer regimens for the year. That means that for the first couple months of any calendar year, every inhaler I try to refill or glucometer supply I prescribe is rejected, often with no guidance from the payer as to what its new preferred option is. We play this game every year, and by April we might have it all figured out. It is a huge waste of time. It also causes significant lapses in patients' access to their medications and supplies. As a result, people completely run out of insulin and albuterol.

In West Virginia, we have only one payer participating in our health care exchange. If one of their customers comes to my office and has chest pain along with all the risk factors for coronary artery disease (high cholesterol, tobacco use, diabetes, high blood pressure, a strong family history of heart attacks in first-degree relatives at young ages), they will not be able to get a stress test. I have fought to get a stress test approved in every way imaginable. I have written letters, I have gone through the multiple prior authorization steps and even done the dreaded peer-to-peer phone calls where I literally plead my patient's case and need for a cardiac stress test.


I explain that these patients will end up dying of a heart attack without the appropriate testing at the appropriate time.

Still denied.

This insurer will pay for the stress test if the patient is seen by cardiology -- sometimes. I had one patient's stress test denied even when ordered by cardiology. These patients end up in the ER the next time they have a worsening episode of chest pain, some with elevated troponins and having the heart attack that we were trying to prevent months ago.

Opiates are a hot topic, especially here in West Virginia. One of the preferred options that payers will cover rather than topical lidocaine gel for pain is oxycodone. The rationale is because it's cheaper, not because it is safer and not because it is the right treatment for the patient.

I have had similar alternative treatment suggestions from insurance companies for chronic migraines. I had extended-release propranolol denied for migraine prophylaxis, but dilaudid was listed as preferred. That is nowhere near appropriate care for migraines.

I don't do inpatient medicine, so I can't speak firsthand to the denials or the process those physicians endure. But I can tell you my patients are often denied coverage for admissions. Patients are furious when they come in for their hospital followup appointments because they were notified in the hospital that their insurance had decided the stay wasn't covered. I see the documentation in the admission history and physical and cannot understand how the ICU isn't covered for conditions such as sepsis, heart failure exacerbations with elevated troponins and diabetic ketoacidosis. A physician colleague told me that one of her patients had an ICU stay denied because the patient improved so quickly that they were discharged in less than 72 hours, so surely, they had not actually been sick enough to warrant ICU-level care.

I want patients to know the truth. The denial letters insurance companies send often say things like, "This test was denied because your doctor failed to submit necessary information." In reality, I've sent every detail from the entire chart, all of which every physician would agree warrants approval. I want patients to know how hard we fight and how upset we become when what we think is in their best interest is denied by payers. These are burdens we feel, burdens that come home with us and cause some of us to eat too much ice cream after work. These are burdens that our spouses have to listen to us complain about night after night. I don't stop worrying about the patient when the insurance company throws a roadblock between them and what I think they need -- I worry more. I worry about how much worse their problem will get when a diagnosis is delayed or a treatment isn't accessible. And I don't worry from a legal malpractice standpoint, I worry because our health care system is failing our patients, and it is driving good, compassionate doctors out of primary care. We can only carry so much, and payers have realized that they can push us to the breaking point with all the administrative hoop-jumping they have created.

I am not writing this because I have answers, I'm writing because I'm desperate for change. I'm tired of being angry all day. I'm tired of losing.

We all have the power to make change. We all have a duty to stand up, to dive in deep to make policy changes at whatever level is accessible to each of us individually. My state chapter recently utilized the AAFP's Speak Out tool to make it easier for us to email our state legislators about a prior authorization streamlining bill. The tool is often used for federal legislation, but it is sometimes aimed at state issues, as well.

Until more patients take up this cause with insurance companies themselves, it is up to us to raise awareness that they often aren't making the right choices for patients.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 10:43AM Mar 05, 2018 by Kimberly Becher, M.D.

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