Most medical students understand that a good chuck of their day as practicing physicians will involve clicking through electronic health records and completing paperwork. But I do not think it is ever made clear how often we will interact with insurance companies. Of course, this will vary by specialty, but everyone entering medical practice should have a basic understanding of prior authorization.
I recently saw an Instagram post from Dr. Austin Chaing about the frustrations of prior authorization — a process wherein medical care will only be paid for if it has been pre-approved by the insurance company. There are a number of reasons insurance companies require preauthorization, including age, medical necessity, and availability of a generic. If a prior authorization is denied, a healthcare provider may file an appeal based on their assessment of the patient and the recommended treatment or medication.
Dr. Chaing’s visible and explained exasperation stemmed not only from the amount of time he spent on the phone with the insurance company, but the content of the conversation — a patient was denied a procedure based on outdated research and the company estimated it would take 10-12 months to re-review it’s policy.
While I have an understanding of prior authorization, Dr. Chaing’s post was another reminder about all the things medical schools don’t teach students — including a lot of insurance lingo and the realities of our time spent on tasks other than direct patient care. If a medical school curriculum was actually based on what studies show doctors do all day, a good majority of the learning would be on paperwork.
A study from the Annals of Family Medicine used an EHR to examine the work of 142 family medicine physicians over a three year period. The doctors spent more than of their time — 6 hours out of an 11 hour day — on the EHR; an hour and a half of that time was after clinic had closed for the day. Another study from Health Affairs analyzed over 31 million EHR interactions of 471 primary care physicians over three years. It found that physicians nearly evenly split their time between direct patient care and electronic medical record keeping.
In addition to keeping up with the ever evolving documentation requirements of EMR systems, many doctors also interface with payers to ensure that prescribed medication and procedures are covered. Each health plans has a different formulary for what is covered and prior authorization requirements. One study estimated that it costs the entire health care system between $23 billion and $31 billion annually to interact with health insurance companies. Another survey found that 46% of physicians had trouble getting approval from insurers on 25% or more of preauthorization requests for tests and procedures; the same was true for drug approval for 58% of physicians. Nearly two-thirds (63%) of physicians indicated waiting several days for approval and 64% and 67% pf physicians had trouble determining what procedures and drugs, respectively, needed prior authorization.
Insurers have stated that the purpose of prior authorization is to provide cost saving consumers by preventing unnecessary procedures and the prescribing of expensive brandname drugs when generic alternatives exist. However, a study in the Journal of the American Board of Family Medicine found that it is much more expensive for a physician to complete the prior authorization process (between $2,161 and $3,430) than the insurance company ($10 to $25 per request).
As it currently exists, prior authorization is a significant burden on medical providers and patients. A survey from the American Medical Association found that over the last five years, half of providers indicated that the burden of prior authorization has increased significantly. It reported that, on average, a medical practice will complete nearly 30 prior authorization requests per physician per week, which will take nearly 15 hours to process.
While most prior authorizations are ultimately approved, it still takes a substantial amount of time that reduces that time providers can spend with patients. The delay in patient access to treatment and medication can be deleterious to patient clinical outcomes. Seventy-eight percent of providers in the AMA survey said that their patients sometimes, often, or always abandon a treatment protocol if they have to wait for prior authorization approval.
At some point, every physician will have to deal with an insurance company regarding patient care. It is just one of the realities of our fragmented health care system — each payer (private vs public), each insurance company (BCBS vs. United vs. Cigna vs. etc.), even different plans within each company cover treatments, procedures, and medications with varying breadth. One company may requires prior authorization for one antibiotic but not another, while another plan may not even cover that antibiotic to start with. While medical students will, most likely, not be participating in the prior authorization process, it is something that will become part of their “hidden” curriculum when they enter residency — not a clinical competency they need to master, but something that is necessary to be a competent physician in our current system.
Image from the American Medical Association.