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.
Michael Strickland, MD
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).
Staff: CT scheduled for 9 a.m. tomorrow.
Dr : Great. Next patient..
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.