Increase in Prior Authorization Mandates

Bruce  0:03  
The idea that they were going to both at the same time that they were announcing decreasing privatization and then adding a whole new arena of privatization in terms of endoscopy codes really was quite a shock.

Terry  0:15  
A baffling decision from one of the largest insurers in the country could affect hundreds of 1000s of patients. Dr. Bruce Hennessy joins us to discuss this new prior authorization policy up next. Welcome to the patients rising podcast. I'm your host, Terry Wilcox, CEO of patients rising. I'm joined by my co host, who is flying out to LA to end this writer strike because he's tired of watching Sabrina the Teenage Witch reruns.

Bob  0:45  
Oh, I love the witch too.

Terry  0:46  
He's Bob Goldberg, co founder of the Center for medicine in the public interest. So are you a Melissa Joan Hart fanboy.

Bob  0:55  
Well sort of because you know, for some reason, the back in the day, she stopped following me on Twitter. So I felt charmed by that maybe part of her witch's spell. But the reason I'm watching the show is because the prequel series, the chilling Adventures of Sabrina is on hiatus be because of the strike. And I I love the premise. I love the fact that it's a darker Serena half sorcerer, half mortal, standing against the evil forces that threaten your family, which is kind of like what we do here on the podcast. Except we're full on humans. As far as I know, Terry, as far as you know, as far as I know, but I'm sure about you. I'm not so sure about myself. But in any event, we don't have a writer strike to worry about. So I'm excited that we can do our show as always. And once again, get to talk to you and our audience about the latest health policy news that impacts the chronic disease community.

Terry  1:51  
Well, today's guest gives us a rundown of a decision from United Healthcare that could lead to delays in cancer diagnosis for patients. That's all set to start this week, June 1. Dr. Bruce Hennessy is a gastroenterologist with the Ohio gastroenterology group and the chair of Health and Public Policy at the American Society for Gastrointestinal Endoscopy, otherwise known as ASG.

Bob  2:18  
Dr. Hennessy joins us because UnitedHealthcare recently announced some big changes to the colonoscopy coverage. Most notably, they put numerous colonoscopies, and 61 other reimbursement codes for the colonoscopy is behind a prior authorization blockade. Now, we should note, this doesn't apply to the routine screenings, it does apply to diagnostic colonoscopies, which are used when the patient presents cancer symptoms, along with surveillance, which means that if you have a history of cancer, you'd get a procedure sort of a watchful waiting kind of thing. These now require prior authorization of a anyway, Terry...

Terry  3:01  
Just crazy. And the concerns are that this could lead to delays in cancer diagnosis, 

Bob  3:08  
you think. 

Terry  3:10  
And I mean, just speaking from personal experience, my sister in law who just recently passed away from colon cancer, you know how to routine screening. Her colon cancer was found at stage four when she was 46 years old. I bring this up because she has one daughter, right? And so what does this mean for the future of those like her, you know, who have a family history now have a parent passing away? That, you know, this could come up for? So I'm sure many of the doctors are scratching their heads. So as you heard at the top of the show disbelief is the first thought that came to Dr. Hennessey's mind. And here's Dr. Hennessy.

Bruce  3:50  
I think the announcement that they were going to start prior authorization for the codes was certainly a shock. Number one, because most of what we had heard was that prior authorization really was expensive to implement, did not necessarily result in a significant reduction in the number of approved procedures or for whatever modality that prior authorization was implemented for. But it did result in delays in care. So you might have an initial denial, if you went through a couple of rounds of appeal. Finally, a peer to peer, you would eventually I think 97% of them might get approved. But that resulted in a delay in care. So if you were eventually going to approve a prior authorization doesn't really make a whole lot of sense to start it in the first place.

Bob  4:43  
So why is united doing this? Here's Dr. Hennessy with an answer.

Bruce  4:48  
The most unfortunate thing about this is that United Healthcare has told us that they have data regarding inappropriate use of the procedures. And I guess inappropriate ordering. But they're unwilling to provide that data. I mean, if you know that the procedures are being ordered inappropriately, my hope would be, that's where you would focus your efforts. And they could maybe provide a lot more in terms of education, or if they provided us that information, we could go out and provide more education for our providers. Because most physicians that I know, they have no desire to order tests or testing, that's inappropriate, they want to order the right test.

Terry  5:31  
That's really amazing. And it seems to me that if you had an issue like this to doctor has his point, and you had, and I'm using air quotes, as you know, I love to do when I talk about these things, if you have the data, then what's wrong with sharing, you know, the top line information about the data so that you can then in turn, correct it rather than, you know, punishing patients, which is what this is ultimately going to do.

Bob  5:59  
Yeah. So, you know, I came across an article in JAMA, it's entitled, potentially inappropriate screening colonoscopies and Medicare patients -- this is 2013. And that's to show you something about the science. And they said that, you know, 23% of this cohort, probably, you know, aged 70 to 86 probably shouldn't have gotten these colonoscopy is well, then guidance has been changed. And it was changed because of clinical advances made by the gastroenterology community. So I'm wondering, again, at least share the data, share your reasons for doing it. It is imperious in the worst kind of business practice. But it does also reflect the fact that if you're United Healthcare and one of the biggest integrated providers in the country, you can do this kind of stuff. 

Terry  6:46  
Well and also the irony of the whole situation is that just back in March, the United Healthcare said it was cutting back on 20% of prior authorizations. Yes. But then, of course, it turns around and releases this rule. Well, we you know, we got to find the money somewhere. Yeah, they turn around, they released this rule, which is 61 codes.

Bob  7:05  
Yeah. Yeah. And includes endoscopy -- means all other kinds of procedures that you use to determine and surveil cancers. Simple as that. I just don't get it. That kind of Watchful Waiting is key to reducing the use of unnecessary, you know, chemotherapies.

Terry  7:28  
Absolutely. So, Bob, what do you know, I've heard some rumors around and actually read a few things. If you heard the talk about artificial intelligence playing a role in prior auth. And when

Speaker 3  7:41  
There's a talk of artificial intelligence is being used by certain health plans to deny coverage automatically based upon patterns. And more and more of these kinds of authorizations are going to be data driven, not physician driven. And here's Dr. Hennessy, who does address this.

Bruce  8:00  
 With the use of AI or algorithms to review diagnostic codes, It allows an insurance company to employ an external means of reviewing rapidly, certain facets of a patient's case, and then providing that recommendation to a physician or a provider of some sort, who can then deny the case, based on the recommendations of the algorithm, or the AI that's reviewing the case, whether or not the are the algorithm is correct or not, as is unclear. But it allows for lower dollar procedures, lower dollar tests to be reviewed, because it's now cost effective for the insurance company because they can have a provider sign off and say no, even though the majority of the review process was done external to the provider. 

Terry  8:59  
The biggest concern is of course, the impact prior authorization has on the patient's themselves and their overall health, which Dr. Hennessy addresses.

Bruce  9:08  
What we don't know is what's the impact that that abandonment will have on patients, especially for practices that may not have the infrastructure to pursue prior authorizations or do the amount of hurdles and jump throughs that you have to do hoops to jump through that the insurance companies provides in order to get a procedure eventually authorized. And so are there patients that you know, may have a delay in having a cancer diagnosis? That's always a possibility. Because if they, you know, it gets abandoned or the prior authorization even doesn't get approved for whatever reason. And then that diagnosis is made at a later date. Who suffers in that case? Really? I mean, we don't suffer as the provider, really the patient suffers, the patients are the ones who are caught in the middle of this. And that's what we think is probably the most unfair.

Terry  9:58  
Well as you and I both know Bob 172 that's a big number organizations have signed the letter to UnitedHealthcare about this policy. And we'll have a link in the show notes. It includes organizations beyond the scope of GI, because so many specialties are impacted by this particular prior authorization.

Bob  10:20  
Yeah, there's a role for that we've talked about on the show for AI to play. But in terms of determining who should get access to coverage, I have really big concerns.

Terry  10:30  
Yeah, I have big concerns that there is not especially in early stage of AI. I want to thank Dr. Bruce Hennessy for joining us. Prior Authorization is one of those issues that nearly everyone in our patient community has encountered. And if you have your own story you'd like to share, you can always get in touch with us at podcast at patients rising.org.

Terry  10:57  
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Bob  11:39  
Carrie a few weeks ago, we did an episode on yet another healthcare middleman within yet another acronym GPOs, which are group purchasing organizations. And Dr. Nikki Johnson was on the show talking about how these monopolies are leading to shortages of medicines, including those for cancer, pediatric needs and even pregnancies. And now the Federal Trade Commission has set its eyes on GPO practices.

Terry  12:08  
And that's right. It's part of the Federal Trade Commission or FTC investigation into the role of PBMs. And our good friend of the show pediatrician, Dr. Marion Mass, foreshadowed this issue on a recent episode of our health care policy pop show.

Marion  12:24  
Look, there's been a lot of talk about the pharmacy benefit managers over recent years and it's across the aisle. The model is the same in that both pharmacy benefit managers and group purchasing organizations have that legalized kickback causes a tremendous conflict of interest. But this is very interesting. The pharmacy benefit managers that have come under scrutiny recently. It looks like they're creating their own GPOs their own group purchasing organizations. And I'm wondering if they're thinking, if we're going to have transparency for PBMs pharmacy benefit managers, maybe they're thinking we can shield ourselves by creating a GPO. And so I think if we're going to have scrutiny on PBMs, we might want to make sure that we're having the same scrutiny on group purchasing organizations.

Terry  13:15  
I agree.

Terry  13:17  
Couldn't agree more. You know, Marion's very she's been very vocal about this particular issue her and Nikki both have,

Bob  13:26  
yeah, I mean, they've seen it firsthand, unfortunately.

Terry  13:29  
Well absolutely. And it's so refreshing that the FTC is expanding the probe in this way. It's almost like the ramp up. That's been done around the GPO issue. I'm not saying it's all lost, but it has been ramped up quite a bit to add that focus. I know Adam Fein sends some posts and some talking about it. Definitely free to care has, and many others, folks like Burian have been out there sounding the alarm bells that you cannot just focus on PBMs and ignore GPOs because that's the next place where they're going to hide their eggs. Right again, we will have a link to an article outlining the recent actions taken against GPOs in the show notes and a link to the health care policy pop episode with Dr. Mass if you want to take a listen. Thank you for listening to today's episode of the patients rising podcast. Make sure you share this episode with fellow patients advocates and caregivers.

Bob  14:22  
Yes, and click the Follow button so you don't miss out on any of our upcoming episodes.

Terry  14:27  
We'll be right back here again on Monday with another new episode. Until then, for Bob and everyone at patients rising. I'm Terry Wilcox, stay healthy.