How would you feel if someone who didn't know, was unfamiliar with your symptoms and story, and had never examined you dictated the way you were treated? Would you be upset if the people making those decisions were not specialists or maybe even had the same training as a physician? Unfortunately, this practice is very common today in every doctor's office in America and it is called prior authorization. Today's guest, Dr. Mark Lopatin, is a rheumatologist in private practice who provides us insight today on what prior authorization is and why it is hurting patient care. He describes prior authorization as a process where third party payors (insurance companies both private and governmental) dictate the care being provided to their customers. They often use guidelines for treatment developed by specialty societies that are meant to be used as a guide for treatment - not as an algorithm to be followed blindly by physicians. Not only does this treatment protocol fail to allow physicians to individualize the care they apply to their patients but it adds tremendous costs to the physicians in their offices. Now practices need to hire extra people just to justify the medical decision making on the phone or through emails which drives up the cost of care for private practices and large hospital organizations. We are not only about problems but also solutions so here are the three reforms to prior authorization that Dr. Lopatin would like to see implemented. Great Transparency: We need to have the true cost differences related to the restrictions on treatments or medications and the reasons those exist. They can't just be buried in the legalese on some insurance company website. Peer-to-Peer Reviews: Only people with a similar background to the treating physician can impede the authorization of treatments from the providing physician. It is ridiculous that someone might be specialist in say kidneys (nephrologist) making treatment recommendations to a cardiologist. Insurance companies who deny care or change treatment should be held legally liable for their medical decisions: Self explanatory but if physicians are expected to be held responsible for treatment then so should those who change the way their patients are cared for by restricting or making erroneous recommendations. Dr. Mark Lopatin is a rheumatologist in private practice in Pennsylvania and the chair of the Montgomery County Medical Society. show notes
@LopatinMD: Twittering for Dr. Lopatin
Pennsylvania Medical Society: A place to search and find more of Dr. Lopatin's writings and activities
Who Should Make Your Medical Decisions?: The Article written by Dr. Lopatin exploring the problems of prior authorizations
Adventures in Prior Authorization: Appeared in the New York Times Opinion Section in 2014
The Impact of Prior Authorizations: A good synopsis of the problem with prior authorizations
Former Aetna Medical Director Admits to Never Reviewing Medical Records Before Denying: Published in Forbes magazine
AMA Prior Authorization Study: Sponsored by the AMA, a reflection of the impact of the prior authorization process on physicians.
Episode 005: What Happened to all the drugs? A discussion of PBMs (Pharmacy Benefit Managers) with Marion Mass
Episode 013: Dr. John Hunt hilariously relates how he charged the insurance companies for doing prior authorization work and almost lost his job with the university
Memorial for Andy Larson: This is the donation link to honor Andy's death with the Grand Rapids Choir of Men and Boys where he blossomed and served as a head chorister.
YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page.
Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.
