Conway McLean, DPM, Journal columnist

Healthcare in the United States is big business. America spends nearly $4 trillion on health care, making it the most expensive system in the world. With those kinds of numbers, funding our medical care brings some high powered players to the table.

But other than Medicare and Medicaid, both of which are federally administered plans, the other parties involved are the private insurers. They are in the business of paying for the care of millions of Americans. And they’re paid handsomely to do so.

Unfortunately, the average citizen knows little about health insurance, how it works and how it doesn’t. Rarely is anyone taught what a deductible is, or how copays work. Staff at most healthcare providers have often been asked “Why doesn’t my insurance pay for all of this?”

Our system ranks very poorly amongst the developed countries of the world. It is far more expensive with a higher incidence of the general markers of disease. But then, we are the only industrialized nation in the world using a for-profit model for funding healthcare. Health insurance for seniors is provided by Medicare, which is a governmental agency, and it has its share of problems. But no one at Medicare is profiting from the business of funding senior America’s healthcare. This is not the case with the privates, who profit from withholding payments and denying treatment.

Many Americans have experienced the rejection of one of their health insurance claims, a rare occurrence in days of yore. The reasoning for the rejection is often lacking or obtuse, generally arbitrary, sometimes even a little ridiculous. The frequent rejection of claims should be understandable since the insurers now utilize computer programs to issue summary rejections of claims without performing an evaluation. There is often no analysis of the patient’s medical history, their diseases, or treatment course. People with minimal relevant experience are able to issue rapid-fire denials of healthcare claims, whole bundles with a single keystroke.

One of the most frequent tactics utilized by the insurance companies is the Prior Authorization. Once termed ‘pre-certification’, this concept was developed decades ago to prevent doctors from ordering expensive tests or procedures that are not “appropriate,” at least according to the insurer. The aim initially was the delivery of cost-effective care but became a method of withholding care or delaying payments. When multiplied by the millions of insured individuals, the interest alone amounts to a significant source of revenue for these corporations.

Prior Authorizations are particularly infuriating for physicians since it demands a sizable portion of our time, away from our patients, focused on what amounts to bureaucratic demands. Because of this tool, the insurance companies have inserted themselves into the process that is modern medical care. The process seems to be made intentionally burdensome so that physicians and patients often eventually give up and use a cheaper alternative or deny the use of some test or therapy.

The use of “prior auths” by insurers has exploded in recent years. Once upon a time, prior authorizations were focused only on the most expensive therapies, things like cancer care. But that was (relatively) long ago, insurers nowadays require these for the most minor, inexpensive medical charges. Even common radiographic studies and prescription refills may require a prior authorization.

But prescriptions are expensive and prior authorizations are an easy way for insurance companies to save money. Certainly, any therapy or drug requested should be medically necessary, but when a nurse (with monetary restrictions and financial motivation) is able to overrule the patient’s physician, the person who knows best the individual’s medical history, authorities on the topic agree we have a problem.

The insurance companies claim this is a beneficial approach to reign in the spiraling costs of healthcare. Any procedure or drug paid for by an insurer should be the most economical treatment option available for someone’s condition. But in actuality, a paper-pusher at the insurance company is making a clinical decision for which they have scant training. They argue that P.A.’s ensure some service or drug must follow up-to-date recommendations for the medical problem you’re dealing with. Too often, the insurance guidelines don’t align with common practice. Typically, the physician is recommending a newer treatment, frequently more expensive, and the insurance company doesn’t want to pay for it.

There is little accountability or oversight in this process. And the implication that patients need protection from their doctors is offensive to many practitioners. Providers must jump through hoops, often spending twenty or thirty minutes on the phone, usually after a staff member has spent twice that, in the process of the typical prior authorization. Commonly, the insurance agent requires that the doctor gets on the phone, taking them away from patient care.

The AMA and other organizations have pushed for regulatory changes, but there has been little improvement. The opposite trend has taken place, with an increasing number of medical costs requiring prior auth’s. They are clearly a delaying tactic, allowing the insurance companies to earn millions of dollars in interest.

We are talking about a multi-billion dollar industry. The financial clout wielded on behalf of these massive corporations is not to be trifled with. But changing the laws has been so far impossible. Most experts agree PA’s benefit the insurers, and not the patient, even causing harm on occasion. Many groups have complained, but nothing has changed, with prior authorizations continuing to be a stressor to physicians, an obstacle to optimal medical care, and a source of frustration to many citizens. It is clear by now, to all that are watching, that the requirement for prior authorizations has helped stress healthcare providers. More importantly, they put patients at risk.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.