Prior auth complaint request :)

[deleted1111261]

Hi, I know this issue brings upon strong feelings. I would like to collect some complaints from you all. Preferably not solely on the clinical questions, but also everything else that is so challenging/awful about it. Radonc specific would be most helpful. This will not be published and obviously anonymous and is going to be used by me to try to suggest ways to improve our processes and make it easier for the physician. I'm not looking for answers from you (but submit if you have any!). It is an ideaboard. I will remove your obscenities.

I understand "the best prior auth is no prior auth," but, as we are stuck with it, I really do want to improve it as much as I can.

Email me: [email protected]

If you don't feel comfortable emailing, you can DM me, that's fine

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[OTN]

Thanks for doing this, Simul- once again proving that you are a leader in our field who is trying to affect actual change.

My first thought: It would be nice for 3D to be able to be used for bone mets for all patients.

 

[TheWallnerus]

Thanks for doing this, Simul- once again proving that you are a leader in our field who is trying to affect actual change.

My first thought: It would be nice for 3D to be able to be used for bone mets for all patients.

I understand your sentiment. But I will play a little bit of devils advocate and see if Simul plays along.

What you’re really asking for is to get **paid** for a 3D sim 77295 for all bone mets instead of complex isodose. (The treatment codes are the same either way.)

You can have 3D “be used” for all bone mets patients, today. No problem. Prior auth doesn’t prevent usages, it prevents payments.

 

[deleted1111261]

Yes, and that’s fine and it’s true, but not the point of the exercise 😃

 

[IonsAreOurFuture]

I had a med onc review a request for SBRT last week, they denied it, and the "manager" said they couldn't change the decision.

I complained and requested a rad onc, who also denied it. At least it was a rad onc the 2nd time, bit if I hadn't specifically asked, would not have known.

 

[TheWallnerus]

Yes, and that’s fine and it’s true, but not the point of the exercise 😃

I understand but in OTNs case, which is a bit unique (we aren’t discussing high dollar SBRT or IMRT eg) he calls up prior auth and wants 3D for a 10 fraction bone met case. He gets denied, yet savvy PA person assuages a bit and says “for this case you will just have to accept about $4700 of reimbursement instead of $5000, but you can still do 3D of course.” Or maybe most PA people (Simul PA people) are explaining that nuance (you can do whatever you want, and “underbill” it) already.

 

[deleted1111261]

But, I'm semantic person. I think if you get a CT scan for a photon plan and you contour volumes that is 3D. I don't see a role for isodose complex in modern America.

I read his suggestion as - get rid of complex isodose.

And, I agree with that.

 

[Ray D. Ayshun]

How about every person doing PA has to approve what they would have done to themselves? If one day they get cancer and ask for a treatment they denied, everything they own is taken from them. Their money and valuable possessions are donated to charities, and all their pictures and family heirlooms are burned in front of them.

 

[deleted1111261]

Does the PA get to choose the charity?

 

[Ray D. Ayshun]

Does the PA get to choose the charity?

Kind of. If republican, it's planned parenthood, if democrat it's trump.org. if unregistered, it's a fund that will help sc justices eat at Michelin starred restaurants.

 

[OTN]

"You can do it, but you won't get paid for it" is the biggest insurance weasel-out of all time

 

[IonsAreOurFuture]

"You can do it, but you won't get paid for it" is the biggest insurance weasel-out of all time

Yes, I got the same response just last week:

P. Auth: "SBRT isn't medically necessary, it is being denied."

Me: "So, you are denying treatment, why again?"

"P. Auth: "Oh, I'm not denying treatment, you can still treat if you believe it's necessary."

Me: "But it won't be covered?"
" How is that not denying treatment!?"

P. Auth: " we don't deny treatment...we don't deny treatment...we don't..."

I think he had to keep saying that as a balm to his ego.

Our therapists are barred by admin
from turning on the machine unless auth is obtained, and dosimetry won't finalize a plan either, so pretty much nothing is going to happen without an insurance pre-auth, and the reviewers know it. I think they can't handle the cognitive dissonance of being a doctor and hurting patients for money, nor should they.

You could literally be the world's leading expert in a disease and have the best quality equipment, an outstanding team, doing absolutely what the patient needs, with guideline support. And yet, the patient's care still gets decided by a retiree or forced- out former physician who doesn't know what the heck they're even talking about, who is literally just reading off a page from a coverage policy written years ago to serve an insurance company's own selfish needs.

The other weasely lie in the whole process is sneakily inserted into the fine print somewhere: "Prior authorization does not guarantee payment. Payment is determined by subsequent review of patient benefits and may be subject to change."

 

[Mandelin Rain]

I hate the lines:

"Yes, I understand and agree 100% with you. It's what I'd do for my patient as well. But that is not covered by the patient's policy. So... I can't do anything and you must submit a written appeal."

Note: This is typically after weeks of waiting to hear back from insurer, waiting days to schedule the peer 2 peer, waiting by my cell phone for the call to happen, and then spending 10 minutes pleading my case. Like... why are you wasting my damn time?

 

[NotMattSpraker]

I understand but in OTNs case, which is a bit unique (we aren’t discussing high dollar SBRT or IMRT eg) he calls up prior auth and wants 3D for a 10 fraction bone met case. He gets denied, yet savvy PA person assuages a bit and says “for this case you will just have to accept about $4700 of reimbursement instead of $5000, but you can still do 3D of course.” Or maybe most PA people (Simul PA people) are explaining that nuance (you can do whatever you want, and “underbill” it) already.

Sounds great.

Then next year we will have graphs about the appalling 6% cuts in life improving palliative - no SAVING (Gillespie, 2023) - radiation and how this pales in comparison to the cost of immunotherapy. Become an ASTRO member, we are the only ones preventing one of your most common treatment techniques from going to $0 tomorrow. Donate today.

I would write more about how you definitely go to jail for "underbilling" but I need to go finish this appeal letter for 20 fractions of on table adaptive whole breast proton RT. This 97 year old lady is so cute, you monster #FixPriorAuth

 

[CurbYourExpectations]

Why not get a PA group that only has RadOncs as evaluators? Run a survey showing its less time spent for everyone involved (less overall money being spent on nonsense) and better QoL. Show that doctors are more up to date on why they are choosing these options, such as new studies that aren't yet on algorithmic NCCN guidelines that do provide benefits to patients years in advance to what others are recommending. Etcetera.

 

[CurbYourExpectations]

How about this as a future:

1. Plan generated from the treating physician and artificial intelligence
2. PA combines with peer review and instantly puts the plan out for anyone to review on the PA plan evaluation website, kind of like a MedNet type situation
3. That plan gets evaluated for reasonableness by 5 practicing RadOncs that all get paid by the PA company for participating in plan evaluation. If docs agree to vote on the plan they have to be willing to argue their reasonableness for the plan.

This could also one way to keep Physicians important in the future. Make US the integral part to this.

 

[Chartreuse Wombat]

^^
Sorry to be negative but now you are paying for 5 MDs instead of 1. Some of the costs could be mitigated by using AI to schedule arrange etc (no nurses etc answering phones) but I suspect too much labor cost.

 

[deleted1111261]

Why not get a PA group that only has RadOncs as evaluators? Run a survey showing its less time spent for everyone involved (less overall money being spent on nonsense) and better QoL. Show that doctors are more up to date on why they are choosing these options, such as new studies that aren't yet on algorithmic NCCN guidelines that do provide benefits to patients years in advance to what others are recommending. Etcetera.

We do solely ROs that are full time employed clinicians. I think that is part of what makes it somewhat less awful.

 

[CurbYourExpectations]

^^
Sorry to be negative but now you are paying for 5 MDs instead of 1. Some of the costs could be mitigated by using AI to schedule arrange etc (no nurses etc answering phones) but I suspect too much labor cost.

No offense at all taken from me, I'm not trying to give the best possible option right now. I am just saying something that I think should be implemented to keep physicians involved from all aspects of the treatment. Before it is just AI making all the decisions.

 

[NotMattSpraker]

No offense at all taken from me, I'm not trying to give the best possible option right now. I am just saying something that I think should be implemented to keep physicians involved from all aspects of the treatment. I'm not the smartest person, but I think it could be good for us and patients.

The plans get uploaded anonymously, meaning no one knows who the treating physician is. The first 3 or whatever physicians available can look at the plan, kind of like people reading over a case on medhub and voting on it, but with patient oriented outcomes prioritized, both from a plan perspective and dosimetrically. Serves as PA from just the plan perspective and from the dosimetric perspective serves as a quality assurance session like a peer review by having multiple physicians evaluate both aspects. The physicians that are evaluating get paid some kind of per service rate that they can do from a less busy work schedule, or from home. The first three physicians that are available to evaluate a plan can log in at any time to a site and help out with plan evaluation and prior authorization. The PA people get a vote from the trained physicians that are not the treating physician, if it favors to treat the PA company pays for treatment, if not, it has to be reevaluated and the physicians that spoke on it have to be willing to nonanonymously say why if it comes to it.

I think this is a great idea in theory but would probably actually be better with computers that aren't fatally biased by conflicts of interest and dogma.

The problem is what are "patient oriented outcomes"?

What is the question you will ask? "Do you favor to treat?"

Who are the voters? Specialist academics? 😬

Imagine a breast PA among a treating specialist and 3 specialist voters using this system haha. The debate could go on for years!

In this system, Id actually take a step back in this system and ask why this feels like you are peer reviewing my treatment decisions. You made me get boarded and do your stupid questions every week. You already make me peer review with my partners.

Why are you now having a panel vote on my treatment decisions too?

We really have to come at this discussion by first being honest with ourselves about incentives for both the PA company and the physician. Everyone keeps starting from this imagined reality where everyone is trying to improve "quality", but no one has even really defined it.

That is not the reality we live in.

 

[deleted1111261]

#MOC4LYFE

 

[RickyScott]

We do solely ROs that are full time employed clinicians. I think that is part of what makes it somewhat less awful.

What type of plans do you represent: employer funded plans vs Medicare advantage?

 

[CurbYourExpectations]

I think this is a great idea in theory but would probably actually be better with computers that aren't fatally biased by conflicts of interest and dogma.

The problem is what are "patient oriented outcomes"?

What is the question you will ask? "Do you favor to treat?"

Who are the voters? Specialist academics? 😬

Imagine a breast PA among a treating specialist and 3 specialist voters using this system haha. The debate could go on for years!

In this system, Id actually take a step back in this system and ask why this feels like you are peer reviewing my treatment decisions. You made me get boarded and do your stupid questions every week. You already make me peer review with my partners.

Why are you now having a panel vote on my treatment decisions too?

We really have to come at this discussion by first being honest with ourselves about incentives for both the PA company and the physician. Everyone keeps starting from this imagined reality where everyone is trying to improve "quality", but no one has even really defined it.

That is not the reality we live in.

Completely agree. I'm just trying to say something that could help all RadOncs in theory. Anonymous peer review and prior auth at the same time. No one shamed, no one's feelings hurt, making it multiple radoncs so that it would have to be something that if it was a truly bad plan it would be based on an anonymous vote unless there was a big discrepancy of repeated submissions.

I don't think this is what will happen, I think this is what is best for RadOnc physicians to happen.

What I think will happen is much worse and I don't want to talk about it openly yet.

 

[deleted1111261]

Completely agree. I'm just trying to say something that could help all RadOncs in theory. Anonymous peer review and prior auth at the same time. No one shamed, no one's feelings hurt, making it multiple radoncs so that it would have to be something that if it was a truly bad plan it would be based on an anonymous vote unless there was a big discrepancy of repeated submissions.

I don't think this is what will happen, I think this is what is best for RadOnc physicians to happen.

What I think will happen is much worse and I don't want to talk about it openly yet.

not the same but I was trying to set up a program for PA for solo docs as an add on for our service. I wonder if people would pay for that.

 

[CurbYourExpectations]

not the same but I was trying to set up a program for PA for solo docs as an add on for our service. I wonder if people would pay for that.

It is all coming, no stopping. I think making it a physician oriented thing now that we could all participate in willingly and be paid for it as physicians would be good for all of us.

 

[IonsAreOurFuture]

It is all coming, no stopping. I think making it a physician oriented thing now that we could all participate in willingly and be paid for it as physicians would be good for all of us.

Since it's supposed to be "peer" review, I think one rule is that you have to be a practicing clinician who uses the same modality.

I'd also like the reviewers to serve on a rotating duty cycle, kind of like jury duty or weekly chart rounds - if you want the pay, you must also play = put in your time as a reviewer.

I think we would be better at policing our own peers than Evicore, and kick people out of the pool for being repeat offenders - kind of like this board, I guess?

 

[deleted1111261]

Since it's supposed to be "peer" review, I think one rule is that you have to be a practicing clinician who uses the same modality.

I'd also like the reviewers to serve on a rotating duty cycle, kind of like jury duty or weekly chart rounds - if you want the pay, you must also play = put in your time as a reviewer.

I think we would be better at policing our own peers than Evicore, and kick people out of the pool for being repeat offenders - kind of like this board, I guess?

In my opinion, having a protonist serve only protonists is a disastrous idea. I have not found many that work in a center to not think things like T1 basal cell or dcis to be appropriate. I think I’m fair. I’ve even asked you a few times to get an opinion!

 

[Mandelin Rain]

I think only 40 fraction IMRT bone met docs should review 40 fraction IMRT bone met cases.

 

[NotMattSpraker]

I'd also like the reviewers to serve on a rotating duty cycle, kind of like jury duty or weekly chart rounds - if you want the pay, you must also play = put in your time as a reviewer.

This is an amazing idea. This field is super siloed and some people stay in one place their whole career. I have learned so much just by leaving my original (and subsequent) silo.

But also disagree with modality experts. Here is Paul Wallner and Mike Steinberg, in a pretty interesting article actually:

"Based on these responses, the ABR RO trustees judge that PBT is sufficiently available to trainees and integrated into the clinical armamentarium for inclusion of PBT content into the 2023 clinical QE question inventory."

It has a little bonus reminder that in 2012 there were only 10 proton sites in the US. So like 32 additional sites were added to our system with, what... one single institution negative randomized trial in that period? Pretty remarkable.

Anyway, cat's out of the bag. If proton content shows up as early as the qualifying exam, every BC/BE radiation oncologist is by definition an expert, right? The ABR is endorsing that you are safe to deliver proton therapy to the public. Thats the deal with certification.

Certainly any of us can decide on it's meaningful use!

Proton Beam Therapy Training, Experience, and Assessment: Ready for Prime Time - PubMed

Proton Beam Therapy Training, Experience, and Assessment: Ready for Prime Time

pubmed.ncbi.nlm.nih.gov

 

[deleted1111261]

From what I am finding, we don't look at the price/cost. Some companies look at price/cost of chemotherapy/systemic administration and then can have a more targeted approach. I wish we did, though. It would be a shining moment for me to say, "We note that there is a freestanding center that is closer to your home that provides the same treatment at 1/5 the cost. There is no evidence that there is lower quality or efficacy at that center. We recommend that you consider this option, as no copay will be needed. If you choose BIG NAME FANCY HOSPITAL you will be required to pay X%"

This is where we find value and savings, without sacrificing quality.

 

[OTN]

From what I am finding, we don't look at the price/cost. Some companies look at price/cost of chemotherapy/systemic administration and then can have a more targeted approach. I wish we did, though. It would be a shining moment for me to say, "We note that there is a freestanding center that is closer to your home that provides the same treatment at 1/5 the cost. There is no evidence that there is lower quality or efficacy at that center. We recommend that you consider this option, as no copay will be needed. If you choose BIG NAME FANCY HOSPITAL you will be required to pay X%"

This is where we find value and savings, without sacrificing quality.

If this were to happen, one can be assured we would see, straight away, quite the volume of cherry-picked studies throughout the Red Journal "demonstrating" improved quality at academic centers.

 

[Mandelin Rain]

If this were to happen, one can be assured we would see, straight away, quite the volume of cherry-picked studies throughout the Red Journal "demonstrating" improved quality at academic centers.

"ASTRO is pursuing legislation through Congress requiring Medicare accepting radiation treatment centers to pass a new, compulsory 8,000 point accreditation that will be available through ASTRO for $250,000 USD annually."

 

[drowsy12]

It would be a shining moment for me to say, "We note that there is a freestanding center that is closer to your home that provides the same treatment at 1/5 the cost. There is no evidence that there is lower quality or efficacy at that center. We recommend that you consider this option, as no copay will be needed. If you choose BIG NAME FANCY HOSPITAL you will be required to pay X%"

This is where we find value and savings, without sacrificing quality.

I'm not sure I agree. This is a slippery slippery slope. Patients deserve options without a financial penalty. What about patients that have clinical trials available? I myself would not want my insurance company to limit my options further on where I can go, cancer or non-cancer. This should already be handled at the contracting stage.

 

[OTN]

I'm not sure I agree. This is a slippery slippery slope. Patients deserve options without a financial penalty. What about patients that have clinical trials available? I myself would not want my insurance company to limit my options further on where I can go, cancer or non-cancer. This should already be handled at the contracting stage.

It's not reasonable to demand that insurance companies accept charges from one center to another that can vary as much as five fold. When that does happen, I would very much expect the companies, in the setting of identical outcomes (which they have data that does indeed show that is what happens, per my discussion with executives) to incentivize their patients to choose the lower-cost facility.

After all, we do care about financial toxicity right? Right???

 

[Mandelin Rain]

Prior auth philosophical question... What's the greater crime?

1. Cancer care is delayed for almost everyone with private insurance. At the very least, delayed for every patient with a need for any procedure that is atypical of insurer derived guidelines. Physician determined necessary care semi-regularly denied for cancer patients. Countless hours of unpaid administrative and physician time lost to deal with this process. Essentially, all good actors punished constantly without reimbursement.

2. A minority of bad actors dole out more costly and/or overutilized care that eats into profitability, and/or in most extreme/rare examples may injure patients beyond inconvenience, for which the recourse of malpractice tort already exists. (Though, it should be noted that there is not truly a quality or safety component to prior auth/UA. Example: it may just blindly catch someone trying to give 120 Gy in 60 fractions to a GBM due to number of fractions but won't stop someone trying to give 120Gy in 30 fractions which is obviously worse.)

 

[TheWallnerus]

Prior auth philosophical question... What's the greater crime?

1. Cancer care is delayed for almost everyone with private insurance. At the very least, delayed for every patient with a need for any procedure that is atypical of insurer derived guidelines. Physician determined necessary care semi-regularly denied for cancer patients. Countless hours of unpaid administrative and physician time lost to deal with this process. Essentially, all good actors punished constantly without reimbursement.

2. A minority of bad actors dole out more costly and/or overutilized care that eats into profitability, and/or in most extreme/rare examples may injure patients beyond inconvenience, for which the recourse of malpractice tort already exists. (Though, it should be noted that there is not truly a quality or safety component to prior auth/UA. Example: it may just blindly catch someone trying to give 120 Gy in 60 fractions to a GBM due to number of fractions but won't stop someone trying to give 120Gy in 30 fractions which is obviously worse.)

This post makes me think something I have never thought before: I’m surprised no one ever pushed for a tiered set of CPT codes based on fractional doses (they were instead based on beam energies).

 

[drowsy12]

It's not reasonable to demand that insurance companies accept charges from one center to another that can vary as much as five fold. When that does happen, I would very much expect the companies, in the setting of identical outcomes (which they have data that does indeed show that is what happens, per my discussion with executives) to incentivize their patients to choose the lower-cost facility.

After all, we do care about financial toxicity right? Right???

Sounds like you’re saying insurance companies shouldn’t pay more than 1 fraction for bone mets, shouldn’t pay for RT for many early stage breast CA, etc etc etc?

 

[OTN]

Prior auth philosophical question... What's the greater crime?

1. Cancer care is delayed for almost everyone with private insurance. At the very least, delayed for every patient with a need for any procedure that is atypical of insurer derived guidelines. Physician determined necessary care semi-regularly denied for cancer patients. Countless hours of unpaid administrative and physician time lost to deal with this process. Essentially, all good actors punished constantly without reimbursement.

2. A minority of bad actors dole out more costly and/or overutilized care that eats into profitability, and/or in most extreme/rare examples may injure patients beyond inconvenience, for which the recourse of malpractice tort already exists. (Though, it should be noted that there is not truly a quality or safety component to prior auth/UA. Example: it may just blindly catch someone trying to give 120 Gy in 60 fractions to a GBM due to number of fractions but won't stop someone trying to give 120Gy in 30 fractions which is obviously worse.)

If we're getting into philosophical questions, then I would call that a false dichotomy- here what I see as the real one:

1. Private insurance allows for prior authorization to occur, which at least does allow for some negotiation between the provider and the payor.

2. Medicare allows for zero negotiation between the provider and the payor. What is covered is covered, what is not is not, and that is that.

 

[OTN]

Sounds like you’re saying insurance companies shouldn’t pay more than 1 fraction for bone mets, shouldn’t pay for RT for many early stage breast CA, etc etc etc?

That is not at all what I am saying

 

[drowsy12]

That is not at all what I am saying

If you’re saying that insurance companies shouldn’t pay more when it doesn’t make a difference to overall outcomes, that’s the end result.

 

[temujim]

From what I am finding, we don't look at the price/cost. Some companies look at price/cost of chemotherapy/systemic administration and then can have a more targeted approach. I wish we did, though. It would be a shining moment for me to say, "We note that there is a freestanding center that is closer to your home that provides the same treatment at 1/5 the cost. There is no evidence that there is lower quality or efficacy at that center. We recommend that you consider this option, as no copay will be needed. If you choose BIG NAME FANCY HOSPITAL you will be required to pay X%"

This is where we find value and savings, without sacrificing quality.

"Same treatment", "quality or efficacy", "quality"....

What do those mean? How could they be measured in the context of rad onc? How would an insurance or a prior auth company know? Many (most? all?) hospitals don't know or care. My employer views MDs as cogs. Quality and outcomes ain't got nothing do with nothing from their perspective.

 

[NotMattSpraker]

Prior auth philosophical question... What's the greater crime?

1. Cancer care is delayed for almost everyone with private insurance. At the very least, delayed for every patient with a need for any procedure that is atypical of insurer derived guidelines. Physician determined necessary care semi-regularly denied for cancer patients. Countless hours of unpaid administrative and physician time lost to deal with this process. Essentially, all good actors punished constantly without reimbursement.

2. A minority of bad actors dole out more costly and/or overutilized care that eats into profitability, and/or in most extreme/rare examples may injure patients beyond inconvenience, for which the recourse of malpractice tort already exists. (Though, it should be noted that there is not truly a quality or safety component to prior auth/UA. Example: it may just blindly catch someone trying to give 120 Gy in 60 fractions to a GBM due to number of fractions but won't stop someone trying to give 120Gy in 30 fractions which is obviously worse.)

Depends who you ask, right? I agree this is exclusively a utilization philosophy debate, links to quality are disingenuous.

For #1, hard to believe hospital administrators care a lot about countless hours of unpaid administrative work and time. Or really anyone in medicine for that matter. This is our line in the sand? Im actually not sure P2P is the time waster I would pick if I had one wish to disappear something that wastes my time in medicine. How about like make it easy for me to change jobs or work without being extrorted by numerous organizations.

Also keep in mind this is hyper-local and calling it punishment is subjective. P2P is not a burden at all to my clinic, we do very few. Nationally, we don't actually know how big of a minority the "bad actors" are in radiation oncology. We cant even agree on what is bad. Personally, I dont think a rad onc having to do a P2P to give proton therapy to T1N0 breast cancer is being punished, sorry. One could argue we are all being punished because of them. Have any of you heard your physicist reminiscing about the good old days when they were billing in vivo dosi and/or special physics consults on every fraction and case? Hard not to feel like an entire generation of rad oncs are being punished for the actions of those practicing 20 years ago.

I think stockholders of insurance companies would pick number 2. Also maybe a lot of government health policy folks. Also maybe ASTRO if you're talking about the right people, like for example that one practice that's still a freestanding Rad Onc in 2023

It's worth remembering that physicians have both decided who needs therapy and how much therapy should cost since the beginning of time. It's a clear and unavoidable conflict of interest that needs to be acknowledged. Over-utilization is a boogey man that probably isnt going away.

 

[deleted1111261]

I'm not sure I agree. This is a slippery slippery slope. Patients deserve options without a financial penalty. What about patients that have clinical trials available? I myself would not want my insurance company to limit my options further on where I can go, cancer or non-cancer. This should already be handled at the contracting stage.

If a high cost center is offering a clinical trial, I am all over that! On my P2Ps where something is not indicated for protons, I tell them that we will support (i.e. pay for) patients to be on an RCT. I feel quite strongly about this.

I truly care about financial toxicity and cost effectiveness. Not from a smarmy POV like many prominent faculty on Twitter. This is not about CV building or media appearances. Personally speaking, since patients have zero skin in the game, they are not incentivized to choose cost effective options. But, I would not suggest that it be out of network or denied. If you want to pianos in the lobby, if you want to see a doctor that is a bone-met-ologist, if you want an IM doctor to do your full history before you see your oncologist, if you want therapy dogs, then perhaps you should have to pay a little bit more (a copay/coinsurance) for that service. Maybe that seems unreasonable to you and that's fair.

From a practical view, if people were more inclined to go to their local center and save money, perhaps the need for PA would be reduced so much that I would have to find a new part time gig?

@temujim - re: quality/same treatment - you know, I don't know, but I think it is odd that you can say you are better and charge more than 5x the amount, while never having to prove you are better. Using Jordan Johnson's transparency tool, I found out my hospital is the cheapest in SE MI. We are half the cost of Beaumont, Henry Ford, UMich. None of the insurers seem to care - they happily reimburse those centers. I am not the best in the area at all thing, but I can treat a bone met or whatever like a GOD. Should I be paid half the amount?

Not arguing, also just philosophical... Very, very insightful posts.

 

[deleted1111261]

Prior auth philosophical question... What's the greater crime?

1. Cancer care is delayed for almost everyone with private insurance. At the very least, delayed for every patient with a need for any procedure that is atypical of insurer derived guidelines. Physician determined necessary care semi-regularly denied for cancer patients. Countless hours of unpaid administrative and physician time lost to deal with this process. Essentially, all good actors punished constantly without reimbursement.

2. A minority of bad actors dole out more costly and/or overutilized care that eats into profitability, and/or in most extreme/rare examples may injure patients beyond inconvenience, for which the recourse of malpractice tort already exists. (Though, it should be noted that there is not truly a quality or safety component to prior auth/UA. Example: it may just blindly catch someone trying to give 120 Gy in 60 fractions to a GBM due to number of fractions but won't stop someone trying to give 120Gy in 30 fractions which is obviously worse.)

Definitely, 100% #1 is worse with PA in it's current form.

I don't think you're describing #2 fairly. We almost never get sued for underdosing. I have a colleague who replaced a doc that underdosed all the SBRT lungs (think 35/5) and that doctor left and the patients are recurring. We rarely get sued for anything compared to other specialties, and I am certain harm is done that would prove to be malpractice. Tort exists, but patients are not aware when to use it. They are more likely to sue you for a bad skin toxicity that was consented for and discussed then for cancer coming back due to inadequate field design or dose, at least in my experience.

 

[temujim]

@temujim - re: quality/same treatment - you know, I don't know, but I think it is odd that you can say you are better and charge more than 5x the amount, while never having to prove you are better. Using Jordan Johnson's transparency tool, I found out my hospital is the cheapest in SE MI. We are half the cost of Beaumont, Henry Ford, UMich. None of the insurers seem to care - they happily reimburse those centers. I am not the best in the area at all thing, but I can treat a bone met or whatever like a GOD. Should I be paid half the amount?

Not arguing, also just philosophical... Very, very insightful posts.

This is a marketing complaint though. Which I am sympathetic to; seeing all the bs billboards and adverts. Funniest one on my commute is the plastic surgeon advertising on a billboard that his board certification is a mark of quality.

But should be part and parcel of limiting direct advertising to patients. All small fish compared to pharma direct advertising which should absolutely be banned.

 

[Chartreuse Wombat]

This is a marketing complaint though. Which I am sympathetic to; seeing all the bs billboards and adverts. Funniest one on my commute is the plastic surgeon advertising on a billboard that his board certification is a mark of quality.

But should be part and parcel of limiting direct advertising to patients. All small fish compared to pharma direct advertising which should absolutely be banned.

 

[deleted1111261]

This is a marketing complaint though. Which I am sympathetic to; seeing all the bs billboards and adverts. Funniest one on my commute is the plastic surgeon advertising on a billboard that his board certification is a mark of quality.

But should be part and parcel of limiting direct advertising to patients. All small fish compared to pharma direct advertising which should absolutely be banned.

If one is going to differentiate between treatment techniques available and to choose more effective ones, if there are contracted facilities that you deem as equal, why should the payor pay full freight for the more expensive one?

I'm not dictating care or where a patient should get it. I'm just trying to think through this idea of never steering and always allowing patients to choose the highest cost treatment, when there is little to suggest there is value for the additional cost.

Imagine a world where everything is Anderson-ized, there are no low cost centers left, and PA is out of control because costs are now 2-3x. There is zero competitive advantage for having lower prices, b/c there is zero skin in the game. The employers should care, as most/many of them are actually shouldering the costs. There is this unbridled anger at payors, but many times the payor is acting as the benefits administrator and the employer is the one wanting to reduce costs.

We claim to value community medicine, community doctors, community care. Even when the community option is excellent and low cost, the larger centers still want to take as much market share as possible. This is fine, if the playing field was equal. But, it is not level at all. And, in my view, this make medical care much more expensive than it needs to be.

 

[NotMattSpraker]

I did not know this until recently. 2023 was a record year for lobby spending. Maybe because of an upcoming lame duck?

Pharma, hospital association, BCBS all spent similar amounts (20m). AMA not far behind (15m). The realtors crush everyone!

I learned this right after I paid about 2x for a house compared to what it cost only a year ago. Yea boy!

MERICA

 

[Chartreuse Wombat]

I did not know this until recently. 2023 was a record year for lobby spending. Maybe because of an upcoming lame duck?

Pharma, hospital association, BCBS all spent similar amounts (20m). AMA not far behind (15m). The realtors crush everyone!

I learned this right after I paid about 2x for a house compared to what it cost only a year ago. Yea boy!

MERICA

ahem...'murica

 

[drowsy12]

If one is going to differentiate between treatment techniques available and to choose more effective ones, if there are contracted facilities that you deem as equal, why should the payor pay full freight for the more expensive one?

I'm not dictating care or where a patient should get it. I'm just trying to think through this idea of never steering and always allowing patients to choose the highest cost treatment, when there is little to suggest there is value for the additional cost.

Evicore's exact logic with their treatment guidelines. Which could go farther and like I said mandate single fraction only, prostate hypofrac only, etc. Of course we all understand the insurance side of it. There's the physician and patient side of it too.