It is not only Aetna, but every major health insurer.

To: Mr. David Jones
Insurance Commissioner of California

Dear Mr. Jones:
I and many of my physician colleagues were gratified to learn in the news this week that you are opening an investigation into Aetna’s ‘prior auth’ practices. I share this little story from today, just so you know it is not only Aetna, but every major health insurer. This is a major reason why our country’s health care is the most expensive, and among the least productive in the developed world (the reverse of just a few years ago), and why U.S. life expectancy has now declined for the second year in a row. I have cc some great physician leaders that I have worked with in California.
Thanks,

Michael Strickland, MD
letmydoctorpractice.org

This is how tests were ordered 10 yrs ago:

Dr to staff: Get a Cat scan (CTPA) of the chest scheduled asap on this patient with recurrent chest pain (who called me last night with worsening pain), now coughing up small amounts of blood (which could become large amounts, at any time, until we know what is causing it), with abnormal fluid collection (pleural effusion).
Minutes later:
Staff: CT scheduled for 9 a.m. tomorrow.
Dr : Great. Next patient..

In 2018:

Tues afternoon:
Dr. to staff (above)
Wed. a.m., I haven’t heard when scheduled. Ask staff. “Hasn’t been scheduled yet. Anthem says it will take a couple of days for them to decide if this test is necessary.” (Note that if the patient gets CT done today and we find a problem, we still have time to do something about it. If Anthem approves it for Friday at 4 pm, there will likely be nothing we can do until Monday..assuming it has not become an emergency, during the delay.)
I call Anthem at 888-224-4902. Get transfer to “provider svcs” 800-345-4344. Get told I need to hang up and call ‘peer to peer line’ at 866-876-3184.

When I call, get voice mail that says “leave your information, and someone will get back to you WITHIN 30 DAYS” !!!!! (I left some information alright).

Call 1st no. back, tell them I want this test approved NOW, or get a Dr. or RN on the phone with me now, or I will send the patient to the ER, and Anthem can pay $5000 to get this done. (Then I remember, the patient has a $12,000 deductible. So, why is Anthem even involved?? “Oh, we still have to approve.”) An RN comes on the line. After a few moments, she says, “Well, a ‘case’ hasn’t been started yet. Your staff will need to call 800-554-0580.” I thank her for her help, tell her this is why I practice direct patient care and do not accept insurance, and ask if she’s seen the news this week that the state of California is investigating Anthem (oops, Aetna. Same thing) over its prior authorization practices.

Give staff above no. She calls and gets CT scan “approved”.

I spent 25 min total on phone w Anthem, plus 15 min w patient and staff, plus documenting (in case of bad outcome, d/t delay), i.e. about one hour of my (doctor’s) time, and staff tells me she spent about an hour on this as well, so 2 hours of the clinic’s time to get “approval” for a test that any 4th year med student would immediately know needs done, and needs done now. And 2 hours we did not do anything remotely resembling anything productive to patient care.

If you wonder why you can’t get into your doctor for days or weeks, and why it costs a fortune, look no further. This happens all day, every day, in every doctor’s office across America.

Next patient…never mind, I’m going to take an aspirin and lie down for a few minutes.

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The Ho$pice Hu$tle?

What’s going on with the recent flurry of acquisitions and divestment in the Hospice industry. IP4P asked HIT-industry veteran Barbara Duck (@MedicalQuack) to weigh in:

“Optum certainly kept this very quiet when they sold their hospice facilities to Compassus; however, they are not out of the business, they want to manage it instead, just as they manage surgeons and physicians with Surgical Care Affiliates and OptumCare doctors.  The worst nightmare for those in hospice has come true, the thought of Optum utilization managers running around Compassus Hospice facilities as they intend now to use Optum Hospice Services to manage them.  Hospice care by the algorithms is what we are looking at here with even more undue and not proven analytical scoring of patients taking place at their last days of their lives.  I think the screen from the PowerPoint presentation on the revenue growth here tells the story of what this company’s (Compassus) goals are, revenue and not patient care being the first priority. Continue reading

PBMs Invade Medical Records and Cash-Pay RX Discount Cards

We wrap up 2017 with a guest post from friend of IP4PI Barbara Duck (@MedicalQuack):

This should not really come as a big surprise as what hasn’t the pharmacy benefit managment business touched?  So what is OptimizeRX?  Most have probably not heard of this software but it is a connect to EMRs that will send your prescription right to the pharmacy.  Oh, now you say, well imagethe PBMs do that and they do but what they have been missing is a way to collect data on patients who are not using their PBM prescription card or those who do not have one.  It’s all about getting more data about you to “score” and of course sell those scores to insurers and other interested parties.  Once the pharmacy has the transaction, it does not fall under HIPAA rules as it’s a prescription, linked to an EMR to provide a transaction.  As we all know, your medications in an EHR are protected but again, I’ll repeat this for those who still think HIPAA is covered at the pharmacy, it is not.  It’s been a sore spot for years with privacy. Continue reading

AMA looks for gold in mining patient and physician data.

Two more items to pitch into “the AMA is utter Garbage” file:

  1. The AMA supports resuscitating the dead-end failure that is the “Affordable Care Act.”  Patients have seen soaring premiums, deductibles, and medical costs, while at the same time often losing access to their doctor and other medical facilities of their choice. Physicians have suffered continued suffocation by ACA red-tape. But the AMA supports propping up this disaster of a law and throwing more good money after bad. 
  2. AMA looks for gold in mining patient and physician data. Why is the AMA advocating against the best interests of doctors and patients? Follow. The. Money. The AMA has discovered it is more lucrative to sell patients and doctors out than to support their interests. Since 1983 the AMA has been making millions of dollars per year from the CPT monopoly it secured in a secret deal with the feds back in 1983. CPT has metastasized into the EHR fisaco that now plagues nearly every office and facility. Now the AMA is hoping to find another pot of gold by mining the data CPT helped to create… patient and physician medical data to be exact. How much can the AMA make of the data? Who knows, but you can read more about the new initiative here: https://healthitanalytics.com/news/ama-launches-integrated-healthcare-big-data-analytics-platform.

Danger, Will Robinson! Danger!

The fatal flaw, or poison pill, of our entire healthcare system … is we’ve tried to make it a system.

Robert Nelson MD of the Georgia Chapter, Free Market Medical Association, writes in:

The fatal flaw, or poison pill, of our entire healthcare system, is that we’ve tried in vane to make it a system.

We set aside everything we knew about human behavior and motivation and behavioral economics and pretended it didn’t exist. We based interventional policy on myths such Roemer’s Law. We tied it to employment by using the tax code. We handicapped markets with McCarran-Ferguson. We handicapped Physicians and other providers with HIPAA. We perverted insurance with all manner of mandate such that it violated every principle of what insurance is supposed to do. This has created Health insulation rather than health insurance.

Then the geniuses thought they can fix it with HMO and then PPOs and now ACOs and all the rest of the alphabet soup that they serve up. All of this has one thing in common and that is price opacity. We have not had a market failure we’ve had one giant pricing failure. We put healthcare on an island and treated it differently and treated it weirdly and regulated it excessively.

Many have gotten wealthy but patients are suffering and doctors are demoralized.

Top Four Reasons Insurance Companies Price Gouge Americans

1.  ObamaCare.

ACA regulations drive costs up and mandates punish those who try to say “no.”

2.  Hospital hidden pricing.

Insurers are complicit with hospitals in blocking patients from price shopping. Insurance CEOs want you to believe you need their product to avoid price gouging but often the opposite is true. Middlemen profit when no one knows the price.

3. Pharma costs.

Ubiquitous third-party payment keeps Rx prices (and premiums) soaring. And the PBM crony capitalists are blocking the pharmacist from telling you that the cash price is often lower than your insurance co-pay.

4. They can.

It’s time for patients and doctors to say “no” to the cartels and demand real options

The AMA is utter garbage. But, you knew that.

Here they go again. Once again the AMA is promoting what’s best for the big government / big insurance / big hospital cartel instead of advocating solutions that will truly empower patients, physicians, and increase access to high-quality, low-cost care.