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    Prior authorization and decision trees: Roots of my frustration

    UT Blogger Profile

    Dr. Rosevear is a urologist in community practice in Colorado Springs, CO.


    While I was in residency, one of the most annoying tasks given to us was “phone notes.” Every day, a pile of notes requiring our attention would show up in a box in the resident’s work room. Some would be patient requests for prescriptions, others would be from patients with questions about upcoming surgeries, and others would be information our attendings wanted us to call a patient about. But the most annoying were the prior authorizations.

    As a small-town urologist, I no longer have to deal with (most) prior authorizations, as I pay my staff to do that. But not a day goes by when I don’t hear one of our nurses or secretaries on the phone trying to work through the automated decision tree to get permission for some medicine, test, or lab that I ordered.

    Talk about a waste of time and resources.

    And while I love urology and think we are a truly special group, I know that urologists are not unique in having to deal with this problem. From drugs to imaging tests to durable equipment, insurance companies create barriers to prevent doctors from being able to order the medicines, tests, and equipment that we deem necessary. I thought the purpose of medical school and residency was to learn what tests to order; I didn’t realize that I should have gone to insurance company school to learn that.

    Have you read: AUA 2017: A small-town plumber's can't-miss sessions

    Why am I so bothered? First, this is not a cost-free problem. While the data are a bit old, a study in 2013 estimated that the requirements for preauthorizations costs approximately $3,430 per doctor per year! Another slightly older study comparing Canada’s single-payer system to ours found that in 2011, the average Canadian physician spent $22,205 per year whereas the average American physician spent $82,975.

    Second, on top of the cost, the stress and hassle that it creates for my staff are almost to the breaking point. Between talking to patients (which is something I have no problems asking my staff to do) and dealing with me (which can be challenging), my staff does not have the time to work through these decision trees whose only discernable purpose is to save the insurance company money. The number one complaint of my staff is having to prior authorize our tests, and the longer I run my practice the more aware I am becoming of the importance of keeping my staff happy. Happy staff interact with my patients in a better way and happy staff also interact with me in a better way.

    Third, I find the concept of prior authorizations simply frustrating. One example: I have started to more frequently order prostatic MRIs as part of my elevated PSA/prostate cancer algorithm. The data behind this test are maturing well and, unlike some of the genetic tests, patients seem to intuitively understand the results. When I tell a patient who is reluctant to undergo a repeat biopsy that he has a suspicious lesion that I may have missed on the previous biopsy, simply based on its size or location, they get it. I haven’t found that to be the case when I give patients the printout from some genetic test and start talking about wolves in sheep’s clothing.

    Next: The real problem I have with insurance companies

    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.


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