The U.S. has the costliest healthcare in the world. We
spend over 16% of our GDP on healthcare, $12,500 per capita. The second most costly is Germany, far below
us at $7,500 per capita1.
You’d think we’d all get concierge-style care
with that price tag. So what do we
get for the most-costly healthcare in the world? Well, our overall life expectancy, as
Americans, is shorter. We rank 50th
amongst all sovereign nations. Compared
to our costs, we’re an outlier. Indeed,
we have a lower life expectancy compared to many so-called rich countries for a
number of reasons—we lead the world in deaths from opioid overdose, homicides,
motor vehicle accidents, and obesity-related illnesses, and we carry one of the
highest infant mortality rates2.
Yet despite our lower rank in health in the face of the highest rank in
cost, many patients find their much-needed therapies are denied by their
insurance companies through a process called “prior authorization (PA)” Often a PA is denied
for reasons that don’t make sense or for no explanation at all. It’s an ugly word in the medical sphere, but even
after an onerous, time-wasting process to get PA, some insurance companies have
the audacity to repeal the authorization AFTER the service is rendered. I’ve dealt with companies that wouldn’t
authorize a surgery, told they’d evaluated it after I performed the
surgery, only to deny payment well after the patient recovered!
Oddly, PAs are sometimes thrown upon us for emergent care. This logic-defying process churns up memory of an encounter I had with a poor patient some years ago, which perfectly illustrates the stupidity of prior authorizations.
* * * The Story * * *
The knife wound cut deep in her face, from forehead down through her
entire nose and upper lip, lacerating cartilage and soft tissue and splaying
her nose so widely, I could easily see the inside of her nasal passages. Multiple smaller lacerations on other areas
of the face and neck were inflicted, along with her legs and arms, severing
tendons over one arm, and multiple stabs into her torso, front and back. This is what we faced, my resident and I, as
we entered the OR. We were in my office
seeing patients when I received the call from the OR: the general surgeon
attending to her multiple other bodily wounds called, and so we quickly excused
ourselves from the patient we were seeing, instructed my office to cancel and reschedule
everyone for the rest of the day, and we rushed to Trios Hospital in Kennewick.
The surgeon had already placed a chest tube to expand a punctured lung
and was exploration her abdomen for any internal injuries laparoscopically. We prepped and draped the face and neck for
our part of the surgery. I proceeded to
repair the severely lacerated nose, while my resident repaired smaller wounds
on the neck and face. The surgeon
attended to numerous lacerations on her legs and arms. The orthopedic surgeon arrived to repair a
hideously lacerated hand and wrist. He
peered at the wound while the nurse prepped the site and jokingly inquired:
“So, how I do I get consent for this? I
suppose it’s implied consent since she’s already under anesthesia?”
“Well, you can get it from her husband,” I said in my typical wise-ass
fashion. “He’s down in the ER,
hand-cuffed to a bed.”
Sure enough, her assailant was none other than her spouse. Her husband slashed and stabbed this
defenseless woman over her entire body—through the chest, abdomen, back, face,
neck and every extremity. He left her
for dead but found he accidently cut his arm in the process, and so he drove
himself to the ER at Trios. In a stroke
of luck, their two daughters came home shortly after the assault, found their
mother alive and breathing, called 911 who immediately transported her to the
hospital ER whereupon the general surgeon was immediately summoned. Only her husband was unaware of this,
thinking she was dead at home, even as he lay waiting on an ER bed to have his
wound repaired. Apparently, someone in
the ER who saw him and the knifed-woman earlier, put two-and-two together such
that the police were called, who arrested and hand-cuffed the bloke to the
gurney.
She had a long recovery, both mentally and physically. I saw her daily in the hospital until she was
discharged and later in my office. Her
wounds healed rather nicely, but she still needed physical therapy to regain
function of her hand and legs. Her
husband is still in prison to this day.
For this particular lady whom I spent hours repairing face and neck
wounds and many hours in postop care over the following weeks, her insurance
company denied payment, saying I did not obtain prior authorization! For an emergent trauma! I’ve encountered this before, where I was
summoned emergently on a weekend or late in the night to treat a patient, often
rushing to the OR, only to have the entire service denied for lack of “prior
authorization.” My staff would later try
to right this with the insurance company, attempting to impress upon them the
impossible and illogical measures they demanded (all decided in retrospect, of
course), that a physician in an emergent situation cannot waste crucial time,
search for the appropriate phone number to call the appropriate person, who
unlikely would be unavailable on a weekend or late in the night, etc., etc.—only
to delay care in a life-threatening condition.
* * *
According to a 2024 survey by the American Medical Association (AMA)3,4,
the majority of physicians feel the number prior authorizations has increased,
which they feel not only delays care, but increases the overall cost of that
care, particularly if the insurer requires other treatment options not
recommended by the doctor, the care is abandoned, or the patient ends up in the
emergency department or is hospitalized due to the illness taking a turn for
the worse.
In the works is a bill (SB 5395) in the Washington state legislature to
improve the transparency and accountability of the PA process, supported by our
state medical society (WSMA). My particular
practice group (Proliance Surgeons, with 160 surgeons and 200+ additional providers)
has also sent several physician members to meet with legislators to push passage
of this bill.
As for my patient: the insurer finally acquiesced to our contention about the PA, though it took multiple calls from my office manager along with a number of baffling processes to have it “authorized”--another costly use of employee time better devoted to something more meaningful. So after multiple hours of surgery, multiple encounters afterwards in the hospital and in my office (not to mention the lost revenue for a half-day’s of cancelled patients), the insurer finally paid a whopping total of (drum-roll)…$172! For all those hours devoted to her care—not including my practice expenses—the insurer valued my professional services at less than minimal wage.
References
1. “Healthcare Spending,” n.d., OECD (Organisation
for Economic Co-operation and Development)
https://www.oecd.org/en/data/indicators/health-spending.html
2. “Life Expectancy at birth, total (years),” World
Bank website
https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2021&most_recent_value_desc=true&start=1960&view=chart This website shows the most recent life-expectancy data per country.
3. Tanya Albert Henry, “Prior authorization delays care and increases health care
costs,” American Medical Association website. Aug 12, 2024.
4. “2024 AMA prior authorization physician
survey,” American Medical Association webpage
https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
©Randall
S. Fong, M.D.
For more topics on
medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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