As physician, the frustration occurs largely because treatment protocols mandated by insurance carriers do not always follow the science. What mystifies most of us is who writes their protocols governing the allocation of care. Compound that with the mystery about how treatment protocols required by insurance carriers are generated. Then, we must deal with reviewers who most likely have never treated a patient or the actual condition at hand. This is to say nothing of peer-to-peer conversations which can be even more frustrating. The "peer" doesn't even work in the same specialty as the one requesting the care. I understand the need to ensure requested care falls with acceptable guidelines, but there is a stark difference between guiding healthcare delivery and interfering with it.
Didn't Trump pass the law *the right to try* so why should it matter if it's an old person or young person. If its something that is going to help the patient then you should be allowed to try. It's sick care not health care. A messed up system. I'm getting out of health care.
I just had an MRI prescribed by my doctor denied TWICE by insurance this last week. Evidently big insurance knows what is best for me more than my personal doctor.
We just went through "prior authorization hell for a treatment that my husband had been having for years and they all of a sudden deny it. He went round and around trying to get to the bottom of it. Unfortunately for them, my husband is persistent as hell and it took him three days, but he wore them down and they finally approved it
With respect, this is incorrect. I don't like the system and it is flawed but the guidelines are not arbitrary (although they may seem so to you). Criteria sets such as InterQual, Carelon and others are evidence-based and refer to things like research and professional society guidelines. They aren't perfect or all-inclusive but they aren't "arbitrary." Also, for 2024, the rationale and guideline that is used to make a denial must be provided/available (at least this is true on the CMS side). This may help inform yourself and your patients and understand what information to provide if you disagree and appeal the decision.
I'm done with Western med. Taking a natural approach to my own health. A 5 step program that's gotten me off all prescribed drugs I was put on for 30 years. I'd rather see an Indian medicine man or shaman than a m.d. or p.a. or f.n.p. I have a chiropractor/acupuncturist that healed my back pain naturally. She does a more thorough assessment than any doctor ever has.
Ultimately it isn't the cdc,fda,NIH or even your doctor's decision. It is and always has been the patients right to choose or refuse a treatment option. The best Dr. We have is the one inside us. Do your own research, ask the right questions. Never accept a prescription as the only option.
Thank you for this! I'm so impressed with your willingness to post an honest view of the prior auth situation, even knowing most of your viewers disagree and you might lose some. I really appreciate your continued fairness and nuanced discussions of all these issues.
I am a nurse ……we really shouldn’t have to interpret or interact with insurance companies…as nurses in an acute care setting in a hospital we have nothing to do with insurance but I can tell you that they have a lot to do with how they pay the hospitals….. food service is outsourced as well as housekeeping…….nurse don’t cook or serve the food nor do we clean the rooms and those services food and housekeeping are not hospital employees…..however if the patient is not happy with their food and they complain or if they are not happy with the cleanliness of their room despite the fact they are VERY happy with their nursing care and the insurance companies know this we get a “ding” which then can effect their paying the hospital and that trickles down to us…..effecting our raises. I have dealt with physicians being upset because they have ordered something and the insurance company tells them that they will not pay….period. There are set number of days they will pay for according to the insurance company and I personally have listened in to a distraught patient being lied to by the insurance company It really only matters to them…..and obviously as long as the patient pays for their benefits it is all about the money. There is no empathy for the patient or the family. Too sick to go/be discharged but insurance won’t pay .
I was the person in the video that went blind. I didn't need medicine, I needed emergent surgery. I have Idiopathic Intracranial Hypertension. I needed to see a neuro-ophthalmologist for an ONSF to prevent my optic nerves from being crushed. The medical group refused to send me outside of their network (they didn't have a neuro-ophthalmologist in network). My doctors and I fought for more than 12 weeks to get that authorization, and by that time my optic nerves were crushed. I've been legally blind since 2008 because of it. ONSF and VP shunts are the gold standard for this condition when medical management has failed and vision is compromised. All of the boxes that needed to be checked were checked. Why? Because they didn't want to have to pay for the specialist and hoped I would leave the group instead of demanding care. Because of them, I ended up disabled for 10 years while I learned how to live and function again... while being a single parent to a small child. The system is BROKEN.
@@lahannid legally blind people, like myself, can still see some things. Also, I use technology to help function. I use large font sizes to read, and the "magnifier" to be able to see things. Most people who are blind aren't living in total darkness. You should perhaps educate yourself about disabilities. I work full time and get a lot done, but only because I've learned how to function with my disability, but that took nearly a decade for me to achieve.
Funny you brought up the self implosion of the Roman Empire - we're headed in the same direction but healthcare is the least of the worries at the moment.
Thumbs up for Vinay having the courage to speak truth! I hate insurance companies for the many problems they have caused me as someone 52 years of Type 1 diabetes. Forcing me to switch from a brand of insulin that works for me to a brand that doesn't to save $5 bucks via a middleman discount makes no cents (pun fully intended). But I totally agree that in the real world of medicine more than a few procedures waste of medical resources partially due to incompetence and partly due to maleficence. This video says more about the NYT than it says about health malfunction. Their journalism is getting worse and worse and worse and their circulation a d page count is getting smaller and smaller and smaller. Worse yet they apparently aren't even reading their own newspaper because Elizabeth Rosenthal, one of their own columnists, has repeatedly exposed the cost + 20% clause, most recently in her definitive book "An American Illness." Anyone truly wishing to understand the roots of the high costs and poor outcomes of American medicine should read her book which explains in great detail the numerous causes of both.
As a MRI Tech who has to help Prior Auth get pushed through for outpatients I appreciate your balanced and nuanced take because I feel the same way. Some referring physicians refuse to learn anything about Radiology even though we try to educate them and they order the most unindicated and frivolous MRIs for the wildest differential diagnosis eliminations. In my opinion its doing the patients more harm than good with both the financial and emotional hit of doing such a procedure (MRI is very hard on patients). On the other hand I've called physicians directly begging them to consider doing a Peer2Peer appeal to Prior Auth denials based on the prior imaging evidence and many will refuse because its too much work even though we have compelling evidence their patient has a cancer. It is so incredibly frustrating to me to navigate this broken healthcare system, moral hazard and injury for all - all around - all the time.
@@z352kdaf8324that’s the point, they can’t. $1500 deductible for someone on fixed income with diabetes is a choice between insulin and food. Our healthcare system is not about health. We should stop calling it as such.
My father got a liver transplant. He was given hepatitis C during the Vietnam era in the army, as many of the servicemen were, but didn’t find out they had it until they were very sick. Gave me 10 more years with him.
1. Doctor says patient should be on Remicade 2. Doctors office sends order to Infusion center to begin prior authorization process 3. Patients insurance (Blue Cross) responds that patient cannot go onto Remicade unless they first some non-biologic. 4. Patient is moved to an oral-solid, then observed for 2-3 months. 5. Patient then applies again to get Remicade after the “first line therapy” is tried. 6. Infusion Center files the prior authorization only for the patient to be denied again because Remicade is a 3rd line therapy or may not be approved at all then the patient must take the next drug and then move to a “generic” or “bio-similar” which may or may not have the same effect as Remicade. Patient could be waiting to get the treatment the doctor initially felt was the best treatment for 6months. This is just one example. PBMs control what commercial payers are allowed to make available to providers/patients. It’s all about money
prior authorization is a crazy way to manage care. there are lots of complaints about a national health plan some other countries have, but prior authorization and insurance companies beating you down with bureaucracy is generally much worse. yes, you might find some oddball cases where doctors are picking unproven unwarranted treatments, but everyone knows plenty of cases when prior authorization and out of network treatments just lead to excuses from companies that have way more bureaucracy and time to waste than patients and people give up and get frustrated with trying to get insurance to pay for completely warranted treatments
Thank you for this. I worked for three different health insurance organizations (all of them not-for-profit orgs) going back to 1996 and the bill that became HIPAA law and, later, when the PPACA was passed in 2010. It's hard to explain to people that insurance can never pay for everything a doctor or patient wants, because it would fail in about a week. The fact that health insurance exists at all, and that (until recently) most people were priced out of it unless they were covered under a workplace group plan, is an accident of history. It's a highly imperfect system, and certainly for-profit orgs have an incentive to wring more money out of patients, but it is not and cannot be a free smorgasbord for every unproven or questionable treatment one can imagine. I appreciate you pointing that out and injecting common sense into the discussion. People imagine there must be a malicious human who looks at every claim and declares "yes" or "no" based on their mood that day, and that's just not how it works.
With the expansion of the affordable Care act, they expanded the roles for Medicaid and Medicare. This is reducing the margin for hospitals for these patients, in the total share of patience in their source of insurance has shifted at the hospitals as well. So they increase their prices for the private insurance market by 30% in the private insurance market is reacting by implementing all these processes to try to control the cost. Essentially private insured individuals are paying for all the Medicare and Medicaid patients.
@@kabaduck yep. As I said, it's a highly imperfect system, all stemming back to the accident of history after world wars when wage freezes were enforced and employee benefits were the lever that large manufacturers could pull to attract workers. It's been veering off the rails in different unintended ways ever since. The very idea that you can "insure" your health is contrary to the concept of insurance to begin with. Your home and your car have a finite value that can be calculated. There is no finite value with one's health. You can even get into the history of how hospital care evolved and became revenue-based, stemming back to founders of the Seventh Day Adventist church and people with names like Post and Kellogg who developed "wellness centers" to promote their religious beliefs while profiting from it. They had, and continue to have, more influence over our food and healthcare systems than people realize.
@@darlafitzpatrick8770Good point. Imagine if your healthcare insurer looked at the extent of damage from an accident and just decided to "total" your body and write a check!
Even with the ACA most people still can’t afford insurance unless covered by a group policy and even then the group policy is still too expensive for a good chunk of people.
I nearly lost my colon because of the delays with prior authorization. The medical schedulers and insurance people really put me in a bad place. I eventually had to check myself into the emergency room and get hospitalized before I could receive an expensive medicine called Remicade. -Although this medicine is expensive, it worked miraculously on me. There needs to be some sort of improvement to the system....
Was in the work comp business for 30 years. Part of my career was responsible for approving or denying TX. Believe me I saw some wacky recommendations. Many unnecessary surgeries, esp spine. Feel like I saved lot of people . In WC we were able to direct patients to best possible MDs for 2nd opinions tho.
I watched a story about how insurance companies are outsourcing prior authorizations, and they reward the companies who maintain a 50% denial rate. So what happens is a double amputee needs a wheelchair, and bc his doctor didn’t include how being a double amputee affects his ability to walk (I can’t even….), he was denied a wheelchair. So the doc resubmits the request, and he was granted a wheelchair on the second one. This counts as two separate patients-TWO-even though it’s the same person. So that company gets to report a 50% denial rate. An amputee being delayed in getting a wheelchair may not kill him, but what happens when it’s a treatment for an aggressive cancer? Ppl die before it gets approved. It’s pure insanity. I get that there are two sides to this, but it’s also true that the insurance companies employ a business model that says “deny, delay, defend”, and it’s costing ppl their lives, or at the very least their quality of life.
I've had a swollen cervical lymph node on the back of my neck that the insurance won't allow scans of for years. Also, my pops was denied a heart cath only to find out he had a 90% blockage after ending up in the ER.
Nothwithstanding its reputation for socialised medicine, Australia has a significant private healthcare system funded largely through individuals purchasing insurance on a voluntary (albeit tax incentivised) basis. Our insurers are passive payers - if a hospital/doctor puts a claim in, the insurer pays it. Obviously there are integrity processes, but there's no right of veto (outside of agreed policy coverage). The insurance is becoming unaffordable. Govt tries to supress premiums. Insurers try to squeeze doctors and hospitals. Something has to give.
I"m so glad you posted this. When I clicked based on the title, I was waiting for a diatribe about how onerous the process is, and to be fair, for some treatments, and especially with some insurers, it's a nightmare. As a person who has filled these out, I've had the headaches. As a patient waiting for the treatments, believe me, those headaches get amplified by the fact that you're unwell and this is your hope on the line. But as you rightly point out, someone's got to watch the piggy bank. We have a broken healthcare system that disconnects the guy whose bank account gets drained from the decision to spend. The responsibility for weighing the value of a treatment is transferred to the doctor who's suppose to inform the patient but often does a half-..ssed job of it, and to the insurer who has no personal stake at all in the decision and only cares about the bottom line. When you have people with different agendas and motives making the decisions instead of the guy who actually has to pay the bill, we need someone to step in and be the patient's voice, not just his voice of desperation (the doctor) and not just his voice of reason (the insurer). We need both to prevent waste and quackery. Yes, the process should be streamlined, efficient, and transparent. Yes, we should have an appeals process. I can't think of any insurer that doesn't do these things with their PAs. They're a necessary evil, so if they need reform, use a scalpel and not a sledgehammer.
I have also seen frequent cases where the insurance company recommends a medication that actually failed clinical studies and could not get FDA approval because there’s one positive article somewhere in their compendium of evidence while denying an efficacious treatment. This was most specific to mental health.
As a patient advocate, I often request authorizations (many Drs don't bother or don't know how). If the treatment is "serious", deemed expensive, or is long-term, 2 supportive medical opinions, proof of "standard of Care", history of failed traditional options and inclusion by medical policy are the minimum needed to present a case. I worked in oncology for 6 years, and you're right, the only treatments denied were off-label and even many of those were authorized if listed in the NCCN. What seems to be denied a lot these days are treatment or therapy by out of network providers, "last-ditch" measures without trying less aggressive and more conventional measures and (of course!) IVIG. The rate of denials has been getting worse, even for extensions of existing authorizations for tx proven beneficial, safe and medically necessary.
What can be done for denials of treatment/therapy by out of network providers? Asking an advocate for family/friends/neighbors. (In rural areas, the closest in-network specialist may be substantially further away so a patient may see someone closer who's out of network, but I cannot think of other reasons...) Thank you.
@@bunEmom There are options: (1) before services are rendered: request a pre-authorization based on lack of in network providers, lack of timely access to care, lack of nearby location (depending on your State's laws or terms of policy), lack of other appropriate, trained, experienced providers in a certain condition or diagnosis etc, lack of choice (such as an anesthesiologist or pathologist) (2) after the facts: file an appeal with the claims dept based on those same arguments (3) if an emergency, you should be covered under the No Balance Bill Act, which forces payment at the In Network rate for Out Of Network providers
as someone who owns a mental health clinic, and has worked in the industry at large on the admin side for 20 years, you, like dr. prasad have stated how it should work. And how it used to work. That is not how the system works now. Thanks to the PPACA and Meaningful Use, the insurance companies, just like CMS, have automated many of their processes. One of those processes is the prior auth process. And the time it takes to go thru the paperwork initially, then appeal the denial you know is coming bc as people that are in the trenches we actually see what works positively on patients and would like to not make the patient spend unnecessary time, money, and not to mention the pain/discomfort they are feeling to appease whatever excuse du jour the insurance company is using today is absolutely wild. The insurance company has never had to be the one to have the convo with a patient or their family and say "I know how to fix this. Its actually method A. But bc of your insurance's policies, we must go thru process 1, 2, 3 and then we can go for the method that will work. It is nonsense. Major medical health insurance does not work for the people, it only works for the carriers.
PA is needed due to our perverse system that separates doctors and patients from costs. In my experience The percent of doctors who are naturally interested and competent in cost benefit analysis is about 1.
PA does not deny care. Its denys payment. The insurance company is under no obligation to pay for things that under their contract states. If you don't like the model go have a chat with the NHS of UK or Canada. They are practically bankrupt because they have to pay for everything for everyone. our model isn't perfect, but is sure as hell is better then a bankrupt and over capacity
@@ratulxyI always love when people compared the UK or Canada system to the US. The US system is only better for upper middle class and above. Or you're disabled or over 65. For everyone else the US system is WAY worse. If you cannot afford insurance in America you're boned.
The obsession with health insurance & the resultant excessive regulation has lead to a separation of the providers & patients from the cost of the product itself which is healthcare. This has made health insurance itself the primary product, which no thanks to government regulation is shielded from normal economic forces of demand & supply.
This is why I'm glad I live in Australia because we don't need any "prior authorisation", plus the Australian health system is NOT run for profit it's run on the idea that the patient gets better no matter how much it costs to the insurer.
How would you design the system if you could? Should insurance companies use randomly selected panels of doctors or medical scientists to evaluate treatments that aren't previously authorized?
Dr V - do a video of the lunacy of the ASP + 6% model of reimbursement. I worked for the company that launched the first bio-similar G-CSF and the consultants said we had to charge MORE than the branded molecule to sell any of it - because the physicians would choose the higher priced option since it would mean slightly more profit. Hard to control costs when physicians are incentivized to choose the most expensive option!
There are people who will die because the insurance company doesn't believe the treatment is worthwhile when the insurance company and doctors who work for them are not informed enough to understand the treatment or the illness. Goes both ways when it all comes down to doctors not being educated enough to be responsible for people's lives and insurance companies never being in business to help people.
What nobody seems to want to discuss is, the USA spends more on healthcare but has a less healthy population when compared to other economically advanced countries (virtually all other developed countries, I believe). How can this be? Could it be that we devote most of the massive healthcare spending to cure and very little to prevention, and particularly, much stronger promotion of healthy life styles? Yes, we have far fewer smokers but we also have an obesity epidemic, the long term consequences of which are probably as bad or worse. Even the US military is having trouble finding young recruits who can pass a physical. All indications are that this sad state of affairs is likely to continue. After all, there is far less money to be made from a healthy population. Why encourage a healthy life style when you can make a buck giving someone an injection, essentially for life, instead of maintaining a healthy diet that involves exercise? As always in the USA, follow the money.
Saying we spend it on healthcare though in itself is a misnomer because we're spending it mainly on sick care. People who have done nothing to be healthy all their lives and then we spend exorbitant amounts of money trying to save them from their poor decisions. I'm not saying people don't deserve any care when they're sick at all, but our focus is on sick care, not health and until that changes the problems we face won't change
Excellent POINTS. ESPECIALLY FACT TAX PAYING SOCIETY PAY FOR PEOPLE TO MANY TIMES CHOSE ILL ESS NOT HEALTH...WE SHOULD PAY FOR WELLNESS AND ACTIONS SUPPORTING SUCH.
What happened to journalism that sought to present multiple sides of complex topics like this? I so rarely hear both sides of this issue, but you’re exactly right. Hopefully there’s a solution to these problems somewhere, but it’s not as simple as commonly presented as “insurance denying care to make money.”
It’s not always preauthorisation….. mine was pre op is not needed….. my Dr and the facility thought therefore it was covered. NOPE. Went to Nebraska Insurance appeals 5x….. we got an attorney and ended up paying between the medical bills and legal fees …..$35,000! THANK YOU BLUE CROSS BLUE SHIELD!!!!
I’m a NP in IBD at a large center in NYC and 75% of my job is prior auth denials/appeals. 50% of the time the denial is for ON LABEL expensive biologic medications because the insurance “prefers” and alternate first line. sometimes the alternate they recommend isn’t even for IBD! Insane
As an old RN that also did case management I had the benefit of talking by phone to insurers to solve some of my pts problems. But as a pt needing surgery, I came up hard against what my pts experience. I waited to get approved for my surgeries only to be told all was approved and scheduled. One got cancelled night before because ooops no authorization obtained I was told. The other time 6 months AFTER my gall bladder surgery...I get bills saying insurance denied it. Took months of dealing with the pt phone lines with over seas call centers not understanding my complaint and escalation before I had to make a complaint to state and things got settled. I no longer trust any Drs office OR the phone calls to determine authorizations. I document every call, every name, as I would for my own pts. Can't assume anyone is doing their job and documenting on their own end anymore.
Pragmatic Prasad… Thanks for your quest to push healthcare towards evidence-based medicine. IMO reasonable people who want to make rational decisions should embrace the spirit of your videos
I'm not a "professional" and I never belonged to a union or association like lawyers and doctors. As a result, I suffered with low income employment, without "organized labor" to improve my income. Are doctors and lawyers "too expensive," and isn't it the expense that insurance companies don't like? If a lung transplant only cost $10,000. would insurance be more likely to pay some lower sum? How much does a pacemaker "installation" cost in USA? In Canada, I received a pacemaker "free of charge," but is the cost to government to pay doctors "too high" and some doctors quit the system because they want higher income, and run to USA where a good doctor can fleece everybody with million dollar services.
He's not from Canada, but a cardiologist did try to sucker me into getting pacemaker surgery (which was not needed) and continue to take Eliquis, a designer Pharma drug that's another poison. And that's how many M.orbid D.ictators operate, with bank and more bank in their coffers. Disgusting. Weak ethics.
A lot of people have responded to points you made in the video. I wanted to add another wrinkle. For capitated insurance models (eg Medicare Advantage), it truly does save insurance money to deny care. And MA plans are notoriously bad about denying care for medically indicated treatments.
This is a fundamental dilemma built into third party payment. Where there is no prior authorization (original medicare with medigap) all kinds of procedures are done with little cost justification. Where there is managed care, prior authorization saves the insurance company at the expense of the patient. Some of the worst abuses arise in medicare advantage. Where there is no third party payment, the patient may not be able to afford beneficial care. The US seems to manage this dilemma especially poorly.
In my country....in the past the hospitals were state owned, the doctors got salaries from the state. State insurance negotiated with the pharma companies. Not perfect, but the doc does not want to push something unnecessary on you...he has no profit from it. The state insurance does not need to make a profit for the shareowners.
I have ok insurance but for the most part I cant touch it for my stage 4 cancer. See I chose not to go the Chemo/surgery route to battle this as prescribed. I seen three family members pay a terrible price. My estimation is that the treatments killed them faster than the original disease. Their quality of life was not good. The medical establishment has made great strides in diagnosing cancer but the success rate numbers havent changed in 50+ years. The treatment protocol is a dinasaur and they know it. The new treatment protocols are junk. So my alternative options are directly out of pocket. I strongly believe that my chances of survival are equal or slightly improved. I guarantee that my quality of life is a lot better off. We dont need this healthcare system as much as they have led us to believe. Thats my rant.
Thank you for giving a more objective idea of the process, regardless of personal opinion of PA (I hate it too). My one objection: Yes providers likely prescribe non-scientific regimens, but shouldn’t other physicians be the ones to decide/govern if it should be covered? Especially since these insurance companies aren’t verifying lack-of-coverage with medical professionals.
True story. When I was doing my pathology residency we had someone request a unit of platelets on a patient with a very mild (over 100K) platelet count. When asked why the patient’s physician said, “I don’t want any abnormal values on their CBC.”
Great commentary. As a former insurance regulator who was NEVER in the insurance industry, I found that insurers are no more likely to take advantage of customers than customers are to take advantage of insurers. It seems that no one, including, and not surprisingly, the NYTimes editorial board, remembers that insurers can only cover what they take in via premiums, which are set by guesses about future usage; when usage goes up, so do premiums, so it's to everyone's benefit to keep usage low. The problem is that some time in the past it was believed that people had insurable interests in their own health, which they wouldn't try to damage any more than they'd try to kill themselves, burn down their homes or crash their cars, and that doctors were NOTHING like body shops and would never think of turning up the gas on costs because they had medical oaths. Oh well.
I just love when you have to get prior authorization of a generic medication. Even worse, when it’s been an indicated medication the patient has been on for years.
The solution to doctors trying things that don't work is not prior authorization. It's comprehensive scientific integration with front line medicine and better enforcement of doctors who go against proven medicine. So, if a doctor wants to try something on a fringe case he gets a small team that reviews his case and helps put in the necessary processes to make it as scientific as possible. Then that's reviewed. For doctors who are reckless the state review boards have to actually communicate to ban someone from practicing medicine when they're harming patients.
Okay, as a physical therapist, requiring prior authorization, every two visits for continued care post-operatively starting at the beginning is Just a way to stress us out and add extra stuff to our plate and does nothing to help the patient at all. And I'm talking to you. Blue Cross.
This is why I ALWAYS select high deductible option. Keep your premiums as low as possible. Save the max every year in an HSA. If you need medical care and your insurance won't pay, you will be in a good position to negotiate a cash price for your procedure here in US or other any other preferred country!
As someone that has lupus, MS, SRDS, SPS or also known as SMS, RA and many many many other autoimmune disorders that tags along. Years ago when I was told I could keep my insurance…I was dropped! Now I pay out of pocket for everything! Now I do get as many grants as possible and do TONS of studies (lab rat) just to stay alive. Thankfully I’ve been blessed with a few fantastic docs that REALLY work with me and only give an RX that they think may help. Still though, I run into many docs that try to push something that scares me or I can’t find any research to back up me spending 1000-2500 on a script. Oh how I wish that I could be your pt! Also I’ve had Cervical cancer quite a few times…We’re still chipping away! It sucks! But it is what it is when you have to be the decision maker and pt. Bless you for helping people understand and bringing awareness to so many important things! 💜🙏💜
Hi Dr Prasad, would you consider doing a deeper, more nuanced vid about prior auth? In family practice we seem to spend inordinate time on it both at the initial notification/filing of as well as the front desk handling numerous angry calls from pts. Many times it is a medication pt has been on long term but insurance changed. Abruptly stopping a blood pressure medication can cause big problems, 911 and ER visits. Fangirl since Covid w you and ZDogg. Thanks for all you do to enlighten and inform.
As a pharmacist who works for insurance, specifically in the Medicare space, I can tell you that there are medical directors on board who sign off on criteria. It's also usually a medical director who sign off on appeals decisions. The insurance companies don't blindly make criteria. It's evidence based and, yes, you are correct. There are way more doctors prescribing things inappropriately than you think. And it's really Medicare who dictates these things. If we approve something that shouldn't have been approved, Medicare doesn't reimburse us and we end up losing money in that sense.
Insurance companies have found a way around ACA loss ratios. They bought out PBM's, so when they pay for prescriptions, they are paying themselves and skewing the ratios. That's why the "market" prices for drugs are insanely overinflated.
As a pharmacist, I totally agree. My go to example which is a major headache, but reasonable are prior authorizations for certain opioid regimens (especially when oxycodone isn’t combined with buprenorphine). There may be a valid reason to do it, but there needs to be a plan to get the patient off of them quickly. With everything a provider has to deal with, it is too easy to just send in another prescription for a pain medication rather than the multiple conversations with the patient about how long term use will likely be more worse for the patient.
Ah... The prior authorization boondoggle. As a licensed acupuncturist, I've have long wanted U.S. healthcare to become cash-based, except for accidents and emergencies. When it comes to chronic health problems drugs and surgeries are rarely helpful and often hurtful. Rather, diet and lifestyle improvements combined with functional medicine modalities are the way to go. Currently in my 18th year of practice.
Thank you for your service I am retired nurse and have been getting acupuncture for years. When I was working my insurance partially covered the cost, Medicare only covers acupuncture for back problems which thankfully I don’t have. I found a wonderful acupuncturist who charges 45 dollars for a session for seniors. I see her once a week because that is discretionary spending that adds value to my life.
My “Prior” Authorization” for a cardiac catheterization was DENIED a WEEK after the procedure! It took reaching out to every level of approval to get it approved-unnecessary stress Aetna !!
Yeah, I had to live with those jokers too. I’ve got to the point where I would just refer to Aenta I’m not glad I met ya. That used to be their slogan for a while back in the 90s I think Aetna I’m glad I met you. I never spent so much time fighting with an insurance company in my life.
I wonder if all the illegals that have entered this country have to get prior authorization…..our healthcare system will fail its paying citizens by raising the rates to make up for their loss when they treat the illegals. Hardworking,honest,good American citizens will be strapped with another increase in insurance premiums because this government has allowed these illegals to enter our country…….not vetted, not vaccinated,carrying disease TB, scabies, lice ,bedbugs and God knows what else.
Regulation of insurance is what makes healthcare so expensive. Each individual should decide which treatments they wish to pay for based on personal risk assessment. Government should have no say except what is already covered by general fraud. Stop all government spending on healthcare, let the individual decide.
Insurance artificially inflated costs to satisfy their economic incentive and policies. Medical insurance should be banned. Doctor and hospitals should be forced to operate by the economy of the general public they treat. Not regulated by the expense of corporate profit.
Somebody has to watch the costs. Doctors don't want to think about it. Patients don't want care to be constrained by money. Who do you want to be in control of spending? I have High Deductible ($3000) Health Care. The promise of it is that patients will be incentivized to push back on excess costs and excess care. Storytime: I had a doctor order put me on AB and also order a tick-borne blood panel. The AB resolved the issue. The panel was negative. It cost (me) $560 after Cigna capped it. The doctor had NO IDEA it would cost that much. WHY NOT? She's looking at an internet connected computer. She has my Cigna account number. The contracts are in place and the costs are determined, but the doctor is not shown the cost. What if the doctor saw that the test was going to cost $560 before she ordered it? She would have said, hmm, let's try the AB and if that doesn't work, we'll consider this expensive test. Doctors need the tools to help patients understand the costs and the VALUE of tests.
I think the reason that Americans are so up in arms about this discussion and easily angered by it is because we have been getting the shaft for so long in terms of healthcare. We hear stories from England where they have the NHS and how there is such much less burocracy and red tape. We're spending more money on Healthcare than many other nations, and our life expectancy continues to decline. Americans are pissed at our politicians and the corporate interests that lobby them.
My husband is a type II diabetic. He had success on trulicity a few years ago. He lost weight and was able to wean off all diabetic medication. We now have a child and have slowed down and his sugar and A1c have slowly crept back up. Our insurance is now denying trulicity ozempic and mounjaro which are due Eric medications. But my two friends who are in a weight loss program can get ozempic no problem. Make it make sense. I’m over here panicking with his hyperglycemia and insurance is giving out his medicine for vanity instead of to him who needs it.
It is unconscionable that in this day and age, and in one of the most wealthy countries in the world patients can die simply for not having enough money in their pocket. This is madness.
Dr P! Excellent content! It is very alarming how big pharma, food and tech seem to keep us unhealthy and in need of their assistance! 6 year carnivore and all need for medicines are gone! Take your life back people!
Indeed, same here! If everyone ate purely real food (based mainly or wholly on animal products) I suspect the burden on health services would reduce by 80% and drugs by 95% or so. But we can’t have that of course because of the obscene profits made by big Pharma, some of which ends up in the hands of corrupt politicians and regulators.
@@kathylong469 everything has improved and my wife and i are healthier than our young doctors/dentists! That's a good sign that things are just fine! 🥩🥛💪🧠 Kathy Long👊❤️
PA are a pain for both the patients and doctors, however, what do you do about incompetent doctors, and ignorant people? Ex 1: 29 yr old diagnosed with thyroid cancer. Local surgeon 60 miles from Philadelphia said he could remove the tumor and then had no follow up with chemo or radiation therapy after the surgery. The tumor came back. Luckily, a friend told the son to go immedicately to a major cancer center in Philly! The outcome was very good after getting the right treatment. Ex 2: 56 year old women has pacreatic cancer with extensive mets to the rest of the body with a life expectancy of 6 months. The family opted to go ahead with radiation and chemo and I'm sure you know the outcome would the same. I think the medical community needs stop focusing solely on SAVING LIVES to the realistic outcome of EXTENDING LIFE PROBABLILTY. Extending life for an 18 year old is totally different than treating someone and 6 months to live.
Not much discussion or analysis of exactly what constitutes good “evidence”, in the medical community. Industry sponsored studies are absolute garbage.
The problem with "no prior authorization" (for example, in a PPO) is that an insurance denial coming months later into a recurring course of treatment can leave a patient/family on the hook for many thousands of dollars when an up-front denial would have given them a good chance to re-think the treatment options.
The discussion always returns to the theme of overutilization in healthcare. The percentage of GDP spent in this sector will continue to ratchet up unless economic incentives are dissociated from medical education with a rigorous plan. The hard truth is that the policymakers are bought out and many don’t even know it.
My Medicare Part D actually changed my cardiologist’s prescription. Cigna prescribed for me, refusing outright the medicine my doctor prescribed. They said the two drugs were similar, not identical. The drug the insurance company wanted me to take is not available in doses that suit my small, sensitive and old body. I thought doctors prescribed and insurance companies did other work. I was wrong. I pay $80 a month for this coverage where the insurance company decides I have to take a larger dose of a different drug.
I agree with everything you said. But, I think that we should get a score. If your useless test ratio falls below a certain point, you don’t have to do PAs until your 6 month recalc. I rarely do expensive stuff because there are usually better options, but occ I need the expensive thing and then it’s just painful.
I want Ubrelvy for migraines. Other Triptan meds don't work, which is what insurance required me to try first. Between my insurance company and the "requirements " needed (that have changed from one triptan, which I took, to another triptan) ,and my doctor's PA representative screwing it by either not doing anything or sending insufficient info up for MONTHS, I have waited over a year and still don't have PA. Ridiculous.
this is what RFK calls 'corporate capture' where industries take over their relative governmental agencies, in this case, health care being controlled by big pharma and the health insurance lobbies...
Really appreciate you breaking that down. Wish we'd been able to keep right to try, still, though. I think that was a good, at the very least, temporary solution. Love ya! XOXO
I need a hip replacement but I’m too young and get hip injections to buy me some time. I completely understand that they have to watch the procedures but they take it too far and use the denial process routinely. Every time in my case and my doctors have to appeal. Causes me approximately a month of excruciating pain every 6 months. (I’m basically allergic to pain medication and only take it for actual surgeries). They have all the records, they know it works and yet they still play this game.
I've got universal care and like it way better because none of what you said applies to me. My system has resource constraints but it's accessible. It's awesome to have a system with few constraints but useless if the people who need it can't access it.
Excellent video. And once again, Dr. Prasad makes himself a target by telling the truth.
Yep. Prasad is to healthcare what Trump is to politics.
@@cl5193meaning?
As physician, the frustration occurs largely because treatment protocols mandated by insurance carriers do not always follow the science. What mystifies most of us is who writes their protocols governing the allocation of care. Compound that with the mystery about how treatment protocols required by insurance carriers are generated. Then, we must deal with reviewers who most likely have never treated a patient or the actual condition at hand. This is to say nothing of peer-to-peer conversations which can be even more frustrating. The "peer" doesn't even work in the same specialty as the one requesting the care. I understand the need to ensure requested care falls with acceptable guidelines, but there is a stark difference between guiding healthcare delivery and interfering with it.
100% agree with you.
It’s a pediatrician following an algorithm and just checking boxes. Extremely frustrating
Didn't Trump pass the law *the right to try* so why should it matter if it's an old person or young person. If its something that is going to help the patient then you should be allowed to try. It's sick care not health care. A messed up system. I'm getting out of health care.
Nailed it dude, what happened to VP. He got paid huh…
In other words, lack of transparency is a problem. Too many mysteries that don't need to be!
I just had an MRI prescribed by my doctor denied TWICE by insurance this last week. Evidently big insurance knows what is best for me more than my personal doctor.
We just went through "prior authorization hell for a treatment that my husband had been having for years and they all of a sudden deny it. He went round and around trying to get to the bottom of it. Unfortunately for them, my husband is persistent as hell and it took him three days, but he wore them down and they finally approved it
25% of my job as a PA now is about prior auths or peer to peers. They deny everything unless it meets an arbitrary algorithm. It’s not medicine
With respect, this is incorrect. I don't like the system and it is flawed but the guidelines are not arbitrary (although they may seem so to you). Criteria sets such as InterQual, Carelon and others are evidence-based and refer to things like research and professional society guidelines. They aren't perfect or all-inclusive but they aren't "arbitrary." Also, for 2024, the rationale and guideline that is used to make a denial must be provided/available (at least this is true on the CMS side). This may help inform yourself and your patients and understand what information to provide if you disagree and appeal the decision.
@@eskimoquinn4737sounds like someone gets their paychecks signed by Carleon
total b.s. as someone on both sides of the equation, its crap. @@eskimoquinn4737
I'm done with Western med. Taking a natural approach to my own health. A 5 step program that's gotten me off all prescribed drugs I was put on for 30 years. I'd rather see an Indian medicine man or shaman than a m.d. or p.a. or f.n.p. I have a chiropractor/acupuncturist that healed my back pain naturally. She does a more thorough assessment than any doctor ever has.
Ultimately it isn't the cdc,fda,NIH or even your doctor's decision. It is and always has been the patients right to choose or refuse a treatment option. The best Dr. We have is the one inside us. Do your own research, ask the right questions. Never accept a prescription as the only option.
Thank you for this! I'm so impressed with your willingness to post an honest view of the prior auth situation, even knowing most of your viewers disagree and you might lose some. I really appreciate your continued fairness and nuanced discussions of all these issues.
I am a nurse ……we really shouldn’t have to interpret or interact with insurance companies…as nurses in an acute care setting in a hospital we have nothing to do with insurance but I can tell you that they have a lot to do with how they pay the hospitals….. food service is outsourced as well as housekeeping…….nurse don’t cook or serve the food nor do we clean the rooms and those services food and housekeeping are not hospital employees…..however if the patient is not happy with their food and they complain or if they are not happy with the cleanliness of their room despite the fact they are VERY happy with their nursing care and the insurance companies know this we get a “ding” which then can effect their paying the hospital and that trickles down to us…..effecting our raises. I have dealt with physicians being upset because they have ordered something and the insurance company tells them that they will not pay….period. There are set number of days they will pay for according to the insurance company and I personally have listened in to a distraught patient being lied to by the insurance company It really only matters to them…..and obviously as long as the patient pays for their benefits it is all about the money. There is no empathy for the patient or the family. Too sick to go/be discharged but insurance won’t pay .
I was the person in the video that went blind. I didn't need medicine, I needed emergent surgery. I have Idiopathic Intracranial Hypertension. I needed to see a neuro-ophthalmologist for an ONSF to prevent my optic nerves from being crushed. The medical group refused to send me outside of their network (they didn't have a neuro-ophthalmologist in network). My doctors and I fought for more than 12 weeks to get that authorization, and by that time my optic nerves were crushed. I've been legally blind since 2008 because of it. ONSF and VP shunts are the gold standard for this condition when medical management has failed and vision is compromised. All of the boxes that needed to be checked were checked. Why? Because they didn't want to have to pay for the specialist and hoped I would leave the group instead of demanding care. Because of them, I ended up disabled for 10 years while I learned how to live and function again... while being a single parent to a small child. The system is BROKEN.
That sucks but how are you reading and writing?
@@lahannid legally blind people, like myself, can still see some things. Also, I use technology to help function. I use large font sizes to read, and the "magnifier" to be able to see things. Most people who are blind aren't living in total darkness. You should perhaps educate yourself about disabilities. I work full time and get a lot done, but only because I've learned how to function with my disability, but that took nearly a decade for me to achieve.
@@OceanMcIntyre You sound defensive. Maybe he was educating himself by asking you a question.
I’m so sorry you went through all that! Can you file a lawsuit against the insurance company?
Funny you brought up the self implosion of the Roman Empire - we're headed in the same direction but healthcare is the least of the worries at the moment.
Thumbs up for Vinay having the courage to speak truth! I hate insurance companies for the many problems they have caused me as someone 52 years of Type 1 diabetes. Forcing me to switch from a brand of insulin that works for me to a brand that doesn't to save $5 bucks via a middleman discount makes no cents (pun fully intended). But I totally agree that in the real world of medicine more than a few procedures waste of medical resources partially due to incompetence and partly due to maleficence. This video says more about the NYT than it says about health malfunction. Their journalism is getting worse and worse and worse and their circulation a d page count is getting smaller and smaller and smaller. Worse yet they apparently aren't even reading their own newspaper because Elizabeth Rosenthal, one of their own columnists, has repeatedly exposed the cost + 20% clause, most recently in her definitive book "An American Illness." Anyone truly wishing to understand the roots of the high costs and poor outcomes of American medicine should read her book which explains in great detail the numerous causes of both.
Thanks for shining light on the other side of this debate.
As a MRI Tech who has to help Prior Auth get pushed through for outpatients I appreciate your balanced and nuanced take because I feel the same way. Some referring physicians refuse to learn anything about Radiology even though we try to educate them and they order the most unindicated and frivolous MRIs for the wildest differential diagnosis eliminations. In my opinion its doing the patients more harm than good with both the financial and emotional hit of doing such a procedure (MRI is very hard on patients). On the other hand I've called physicians directly begging them to consider doing a Peer2Peer appeal to Prior Auth denials based on the prior imaging evidence and many will refuse because its too much work even though we have compelling evidence their patient has a cancer.
It is so incredibly frustrating to me to navigate this broken healthcare system, moral hazard and injury for all - all around - all the time.
As a pharmacist, I hate prior authorisation. My patients think I’m denying them. Terrible.
They can pay out of pocket if they think it will help.
@@z352kdaf8324Depends on the pharmacy and the script...controlled substances may not be allowed for cash pay if insurance does not cover it.
😂😂
I'm sure you are tired of the number of off label Ozempic and Mounjaro prescriptions.
@@z352kdaf8324that’s the point, they can’t. $1500 deductible for someone on fixed income with diabetes is a choice between insulin and food. Our healthcare system is not about health. We should stop calling it as such.
My father got a liver transplant. He was given hepatitis C during the Vietnam era in the army, as many of the servicemen were, but didn’t find out they had it until they were very sick. Gave me 10 more years with him.
Do you know if they service connected that?
For your non hospital listeners - a simple clear example of “this is the process of prior authorization” would be useful.
1. Doctor says patient should be on Remicade
2. Doctors office sends order to Infusion center to begin prior authorization process
3. Patients insurance (Blue Cross) responds that patient cannot go onto Remicade unless they first some non-biologic.
4. Patient is moved to an oral-solid, then observed for 2-3 months.
5. Patient then applies again to get Remicade after the “first line therapy” is tried.
6. Infusion Center files the prior authorization only for the patient to be denied again because Remicade is a 3rd line therapy or may not be approved at all then the patient must take the next drug and then move to a “generic” or “bio-similar” which may or may not have the same effect as Remicade.
Patient could be waiting to get the treatment the doctor initially felt was the best treatment for 6months.
This is just one example.
PBMs control what commercial payers are allowed to make available to providers/patients. It’s all about money
prior authorization is a crazy way to manage care. there are lots of complaints about a national health plan some other countries have, but prior authorization and insurance companies beating you down with bureaucracy is generally much worse. yes, you might find some oddball cases where doctors are picking unproven unwarranted treatments, but everyone knows plenty of cases when prior authorization and out of network treatments just lead to excuses from companies that have way more bureaucracy and time to waste than patients and people give up and get frustrated with trying to get insurance to pay for completely warranted treatments
Thank you for this. I worked for three different health insurance organizations (all of them not-for-profit orgs) going back to 1996 and the bill that became HIPAA law and, later, when the PPACA was passed in 2010. It's hard to explain to people that insurance can never pay for everything a doctor or patient wants, because it would fail in about a week. The fact that health insurance exists at all, and that (until recently) most people were priced out of it unless they were covered under a workplace group plan, is an accident of history. It's a highly imperfect system, and certainly for-profit orgs have an incentive to wring more money out of patients, but it is not and cannot be a free smorgasbord for every unproven or questionable treatment one can imagine. I appreciate you pointing that out and injecting common sense into the discussion. People imagine there must be a malicious human who looks at every claim and declares "yes" or "no" based on their mood that day, and that's just not how it works.
With the expansion of the affordable Care act, they expanded the roles for Medicaid and Medicare. This is reducing the margin for hospitals for these patients, in the total share of patience in their source of insurance has shifted at the hospitals as well. So they increase their prices for the private insurance market by 30% in the private insurance market is reacting by implementing all these processes to try to control the cost. Essentially private insured individuals are paying for all the Medicare and Medicaid patients.
@@kabaduck yep. As I said, it's a highly imperfect system, all stemming back to the accident of history after world wars when wage freezes were enforced and employee benefits were the lever that large manufacturers could pull to attract workers. It's been veering off the rails in different unintended ways ever since. The very idea that you can "insure" your health is contrary to the concept of insurance to begin with. Your home and your car have a finite value that can be calculated. There is no finite value with one's health. You can even get into the history of how hospital care evolved and became revenue-based, stemming back to founders of the Seventh Day Adventist church and people with names like Post and Kellogg who developed "wellness centers" to promote their religious beliefs while profiting from it. They had, and continue to have, more influence over our food and healthcare systems than people realize.
@@darlafitzpatrick8770Good point. Imagine if your healthcare insurer looked at the extent of damage from an accident and just decided to "total" your body and write a check!
@@teresabenson3385 haha, exactly!
Even with the ACA most people still can’t afford insurance unless covered by a group policy and even then the group policy is still too expensive for a good chunk of people.
I nearly lost my colon because of the delays with prior authorization. The medical schedulers and insurance people really put me in a bad place. I eventually had to check myself into the emergency room and get hospitalized before I could receive an expensive medicine called Remicade. -Although this medicine is expensive, it worked miraculously on me. There needs to be some sort of improvement to the system....
Was in the work comp business for 30 years. Part of my career was responsible for approving or denying TX. Believe me I saw some wacky recommendations. Many unnecessary surgeries, esp spine. Feel like I saved lot of people . In WC we were able to direct patients to best possible MDs for 2nd opinions tho.
I watched a story about how insurance companies are outsourcing prior authorizations, and they reward the companies who maintain a 50% denial rate. So what happens is a double amputee needs a wheelchair, and bc his doctor didn’t include how being a double amputee affects his ability to walk (I can’t even….), he was denied a wheelchair. So the doc resubmits the request, and he was granted a wheelchair on the second one. This counts as two separate patients-TWO-even though it’s the same person. So that company gets to report a 50% denial rate. An amputee being delayed in getting a wheelchair may not kill him, but what happens when it’s a treatment for an aggressive cancer? Ppl die before it gets approved. It’s pure insanity. I get that there are two sides to this, but it’s also true that the insurance companies employ a business model that says “deny, delay, defend”, and it’s costing ppl their lives, or at the very least their quality of life.
whoever designs these systems are demonic for real its sickening 🤒🙄
I'd love your take on the WPATH files. I think it's another example of ideology being more important than data and what's best for patients.
The whole point of an insurance company is to deny coverage and price gouge.
I've had a swollen cervical lymph node on the back of my neck that the insurance won't allow scans of for years.
Also, my pops was denied a heart cath only to find out he had a 90% blockage after ending up in the ER.
Nothwithstanding its reputation for socialised medicine, Australia has a significant private healthcare system funded largely through individuals purchasing insurance on a voluntary (albeit tax incentivised) basis. Our insurers are passive payers - if a hospital/doctor puts a claim in, the insurer pays it. Obviously there are integrity processes, but there's no right of veto (outside of agreed policy coverage). The insurance is becoming unaffordable. Govt tries to supress premiums. Insurers try to squeeze doctors and hospitals. Something has to give.
I"m so glad you posted this. When I clicked based on the title, I was waiting for a diatribe about how onerous the process is, and to be fair, for some treatments, and especially with some insurers, it's a nightmare. As a person who has filled these out, I've had the headaches. As a patient waiting for the treatments, believe me, those headaches get amplified by the fact that you're unwell and this is your hope on the line. But as you rightly point out, someone's got to watch the piggy bank. We have a broken healthcare system that disconnects the guy whose bank account gets drained from the decision to spend. The responsibility for weighing the value of a treatment is transferred to the doctor who's suppose to inform the patient but often does a half-..ssed job of it, and to the insurer who has no personal stake at all in the decision and only cares about the bottom line. When you have people with different agendas and motives making the decisions instead of the guy who actually has to pay the bill, we need someone to step in and be the patient's voice, not just his voice of desperation (the doctor) and not just his voice of reason (the insurer). We need both to prevent waste and quackery. Yes, the process should be streamlined, efficient, and transparent. Yes, we should have an appeals process. I can't think of any insurer that doesn't do these things with their PAs. They're a necessary evil, so if they need reform, use a scalpel and not a sledgehammer.
I have also seen frequent cases where the insurance company recommends a medication that actually failed clinical studies and could not get FDA approval because there’s one positive article somewhere in their compendium of evidence while denying an efficacious treatment. This was most specific to mental health.
As a patient advocate, I often request authorizations (many Drs don't bother or don't know how). If the treatment is "serious", deemed expensive, or is long-term, 2 supportive medical opinions, proof of "standard of Care", history of failed traditional options and inclusion by medical policy are the minimum needed to present a case. I worked in oncology for 6 years, and you're right, the only treatments denied were off-label and even many of those were authorized if listed in the NCCN. What seems to be denied a lot these days are treatment or therapy by out of network providers, "last-ditch" measures without trying less aggressive and more conventional measures and (of course!) IVIG. The rate of denials has been getting worse, even for extensions of existing authorizations for tx proven beneficial, safe and medically necessary.
What can be done for denials of treatment/therapy by out of network providers? Asking an advocate for family/friends/neighbors. (In rural areas, the closest in-network specialist may be substantially further away so a patient may see someone closer who's out of network, but I cannot think of other reasons...) Thank you.
@@bunEmom There are options: (1) before services are rendered: request a pre-authorization based on lack of in network providers, lack of timely access to care, lack of nearby location (depending on your State's laws or terms of policy), lack of other appropriate, trained, experienced providers in a certain condition or diagnosis etc, lack of choice (such as an anesthesiologist or pathologist) (2) after the facts: file an appeal with the claims dept based on those same arguments (3) if an emergency, you should be covered under the No Balance Bill Act, which forces payment at the In Network rate for Out Of Network providers
as someone who owns a mental health clinic, and has worked in the industry at large on the admin side for 20 years, you, like dr. prasad have stated how it should work. And how it used to work. That is not how the system works now.
Thanks to the PPACA and Meaningful Use, the insurance companies, just like CMS, have automated many of their processes. One of those processes is the prior auth process. And the time it takes to go thru the paperwork initially, then appeal the denial you know is coming bc as people that are in the trenches we actually see what works positively on patients and would like to not make the patient spend unnecessary time, money, and not to mention the pain/discomfort they are feeling to appease whatever excuse du jour the insurance company is using today is absolutely wild.
The insurance company has never had to be the one to have the convo with a patient or their family and say "I know how to fix this. Its actually method A. But bc of your insurance's policies, we must go thru process 1, 2, 3 and then we can go for the method that will work.
It is nonsense. Major medical health insurance does not work for the people, it only works for the carriers.
Retired midwife here, have worked in 3 countries. Agreed. Keep up the good work!
they made more things more expensive not more support
PA is needed due to our perverse system that separates doctors and patients from costs.
In my experience The percent of doctors who are naturally interested and competent in cost benefit analysis is about 1.
PA does not deny care. Its denys payment. The insurance company is under no obligation to pay for things that under their contract states. If you don't like the model go have a chat with the NHS of UK or Canada. They are practically bankrupt because they have to pay for everything for everyone. our model isn't perfect, but is sure as hell is better then a bankrupt and over capacity
@@TheKadoogenatorand waiting in for a long time for procedures.
@ianberlin3214 my friend had to wait for 3 hours at an emergency.
@@ratulxyI always love when people compared the UK or Canada system to the US.
The US system is only better for upper middle class and above.
Or you're disabled or over 65.
For everyone else the US system is WAY worse. If you cannot afford insurance in America you're boned.
@@seemlesslies you're right, I am talking about US waiting time in ER.
OMG I am in awe of you Dr Prasad. You are a hero for speaking the truth and honesty.
The obsession with health insurance & the resultant excessive regulation has lead to a separation of the providers & patients from the cost of the product itself which is healthcare. This has made health insurance itself the primary product, which no thanks to government regulation is shielded from normal economic forces of demand & supply.
Can you imagine healthcare without regulation?
100%
This is why I'm glad I live in Australia because we don't need any "prior authorisation", plus the Australian health system is NOT run for profit it's run on the idea that the patient gets better no matter how much it costs to the insurer.
How would you design the system if you could? Should insurance companies use randomly selected panels of doctors or medical scientists to evaluate treatments that aren't previously authorized?
Dr V - do a video of the lunacy of the ASP + 6% model of reimbursement. I worked for the company that launched the first bio-similar G-CSF and the consultants said we had to charge MORE than the branded molecule to sell any of it - because the physicians would choose the higher priced option since it would mean slightly more profit. Hard to control costs when physicians are incentivized to choose the most expensive option!
Not surprised. It’s a money making operation. 🤷♀️
Always enjoy your perspective Dr. I learn alot.
"timely authorization " may have to be legislated in the near future
There are people who will die because the insurance company doesn't believe the treatment is worthwhile when the insurance company and doctors who work for them are not informed enough to understand the treatment or the illness. Goes both ways when it all comes down to doctors not being educated enough to be responsible for people's lives and insurance companies never being in business to help people.
What nobody seems to want to discuss is, the USA spends more on healthcare but has a less healthy population when compared to other economically advanced countries (virtually all other developed countries, I believe). How can this be? Could it be that we devote most of the massive healthcare spending to cure and very little to prevention, and particularly, much stronger promotion of healthy life styles? Yes, we have far fewer smokers but we also have an obesity epidemic, the long term consequences of which are probably as bad or worse. Even the US military is having trouble finding young recruits who can pass a physical. All indications are that this sad state of affairs is likely to continue. After all, there is far less money to be made from a healthy population. Why encourage a healthy life style when you can make a buck giving someone an injection, essentially for life, instead of maintaining a healthy diet that involves exercise? As always in the USA, follow the money.
Saying we spend it on healthcare though in itself is a misnomer because we're spending it mainly on sick care. People who have done nothing to be healthy all their lives and then we spend exorbitant amounts of money trying to save them from their poor decisions. I'm not saying people don't deserve any care when they're sick at all, but our focus is on sick care, not health and until that changes the problems we face won't change
Excellent POINTS. ESPECIALLY FACT TAX PAYING SOCIETY PAY FOR PEOPLE TO MANY TIMES CHOSE ILL ESS NOT HEALTH...WE SHOULD PAY FOR WELLNESS AND ACTIONS SUPPORTING SUCH.
What happened to journalism that sought to present multiple sides of complex topics like this? I so rarely hear both sides of this issue, but you’re exactly right. Hopefully there’s a solution to these problems somewhere, but it’s not as simple as commonly presented as “insurance denying care to make money.”
It’s not always preauthorisation….. mine was pre op is not needed….. my Dr and the facility thought therefore it was covered. NOPE. Went to Nebraska Insurance appeals 5x….. we got an attorney and ended up paying between the medical bills and legal fees …..$35,000! THANK YOU BLUE CROSS BLUE SHIELD!!!!
Great topic and you have shed more light on this complicated subject for me, thank you!
I’m a NP in IBD at a large center in NYC and 75% of my job is prior auth denials/appeals. 50% of the time the denial is for ON LABEL expensive biologic medications because the insurance “prefers” and alternate first line. sometimes the alternate they recommend isn’t even for IBD! Insane
As an old RN that also did case management I had the benefit of talking by phone to insurers to solve some of my pts problems. But as a pt needing surgery, I came up hard against what my pts experience. I waited to get approved for my surgeries only to be told all was approved and scheduled. One got cancelled night before because ooops no authorization obtained I was told. The other time 6 months AFTER my gall bladder surgery...I get bills saying insurance denied it. Took months of dealing with the pt phone lines with over seas call centers not understanding my complaint and escalation before I had to make a complaint to state and things got settled. I no longer trust any Drs office OR the phone calls to determine authorizations. I document every call, every name, as I would for my own pts. Can't assume anyone is doing their job and documenting on their own end anymore.
The insurance didn't want to give me a MRI.....
Pragmatic Prasad…
Thanks for your quest to push healthcare towards evidence-based medicine.
IMO reasonable people who want to make rational decisions should embrace the spirit of your videos
I'm not a "professional" and I never belonged to a union or association like lawyers and doctors. As a result, I suffered with low income employment, without "organized labor" to improve my income. Are doctors and lawyers "too expensive," and isn't it the expense that insurance companies don't like? If a lung transplant only cost $10,000. would insurance be more likely to pay some lower sum? How much does a pacemaker "installation" cost in USA? In Canada, I received a pacemaker "free of charge," but is the cost to government to pay doctors "too high" and some doctors quit the system because they want higher income, and run to USA where a good doctor can fleece everybody with million dollar services.
He's not from Canada, but a cardiologist did try to sucker me into getting pacemaker surgery (which was not needed) and continue to take Eliquis, a designer Pharma drug that's another poison. And that's how many M.orbid D.ictators operate, with bank and more bank in their coffers. Disgusting. Weak ethics.
A lot of people have responded to points you made in the video. I wanted to add another wrinkle. For capitated insurance models (eg Medicare Advantage), it truly does save insurance money to deny care. And MA plans are notoriously bad about denying care for medically indicated treatments.
This is a fundamental dilemma built into third party payment. Where there is no prior authorization (original medicare with medigap) all kinds of procedures are done with little cost justification. Where there is managed care, prior authorization saves the insurance company at the expense of the patient. Some of the worst abuses arise in medicare advantage. Where there is no third party payment, the patient may not be able to afford beneficial care. The US seems to manage this dilemma especially poorly.
In my country....in the past the hospitals were state owned, the doctors got salaries from the state. State insurance negotiated with the pharma companies. Not perfect, but the doc does not want to push something unnecessary on you...he has no profit from it. The state insurance does not need to make a profit for the shareowners.
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Medicare Advantage is by design and the government/medicare is aware of it.
I have ok insurance but for the most part I cant touch it for my stage 4 cancer. See I chose not to go the Chemo/surgery route to battle this as prescribed. I seen three family members pay a terrible price. My estimation is that the treatments killed them faster than the original disease. Their quality of life was not good. The medical establishment has made great strides in diagnosing cancer but the success rate numbers havent changed in 50+ years. The treatment protocol is a dinasaur and they know it. The new treatment protocols are junk. So my alternative options are directly out of pocket. I strongly believe that my chances of survival are equal or slightly improved. I guarantee that my quality of life is a lot better off. We dont need this healthcare system as much as they have led us to believe. Thats my rant.
Love your analysis, VP.
Thank you for giving a more objective idea of the process, regardless of personal opinion of PA (I hate it too). My one objection: Yes providers likely prescribe non-scientific regimens, but shouldn’t other physicians be the ones to decide/govern if it should be covered? Especially since these insurance companies aren’t verifying lack-of-coverage with medical professionals.
I don’t want any bureaucrat with the insurance industry second guessing my doctor who actually saw me, touched me, talked to me. Period
True story. When I was doing my pathology residency we had someone request a unit of platelets on a patient with a very mild (over 100K) platelet count. When asked why the patient’s physician said, “I don’t want any abnormal values on their CBC.”
Great commentary. As a former insurance regulator who was NEVER in the insurance industry, I found that insurers are no more likely to take advantage of customers than customers are to take advantage of insurers. It seems that no one, including, and not surprisingly, the NYTimes editorial board, remembers that insurers can only cover what they take in via premiums, which are set by guesses about future usage; when usage goes up, so do premiums, so it's to everyone's benefit to keep usage low. The problem is that some time in the past it was believed that people had insurable interests in their own health, which they wouldn't try to damage any more than they'd try to kill themselves, burn down their homes or crash their cars, and that doctors were NOTHING like body shops and would never think of turning up the gas on costs because they had medical oaths. Oh well.
It cannot be stated more forcefully how important this video is to the deep rooted problems in healthcare. The more you spend the more you make.
I just love when you have to get prior authorization of a generic medication. Even worse, when it’s been an indicated medication the patient has been on for years.
The solution to doctors trying things that don't work is not prior authorization. It's comprehensive scientific integration with front line medicine and better enforcement of doctors who go against proven medicine.
So, if a doctor wants to try something on a fringe case he gets a small team that reviews his case and helps put in the necessary processes to make it as scientific as possible.
Then that's reviewed.
For doctors who are reckless the state review boards have to actually communicate to ban someone from practicing medicine when they're harming patients.
Okay, as a physical therapist, requiring prior authorization, every two visits for continued care post-operatively starting at the beginning is Just a way to stress us out and add extra stuff to our plate and does nothing to help the patient at all. And I'm talking to you. Blue Cross.
That's properly pronounced Blue F. Cross. Former biller here.
That's a perspective I haven't considered well thought out and argued
This is why I ALWAYS select high deductible option. Keep your premiums as low as possible. Save the max every year in an HSA. If you need medical care and your insurance won't pay, you will be in a good position to negotiate a cash price for your procedure here in US or other any other preferred country!
As someone that has lupus, MS, SRDS, SPS or also known as SMS, RA and many many many other autoimmune disorders that tags along. Years ago when I was told I could keep my insurance…I was dropped! Now I pay out of pocket for everything! Now I do get as many grants as possible and do TONS of studies (lab rat) just to stay alive. Thankfully I’ve been blessed with a few fantastic docs that REALLY work with me and only give an RX that they think may help. Still though, I run into many docs that try to push something that scares me or I can’t find any research to back up me spending 1000-2500 on a script.
Oh how I wish that I could be your pt! Also I’ve had Cervical cancer quite a few times…We’re still chipping away! It sucks! But it is what it is when you have to be the decision maker and pt.
Bless you for helping people understand and bringing awareness to so many important things! 💜🙏💜
You can cure all of that with a carnivore diet.
Hi Dr Prasad, would you consider doing a deeper, more nuanced vid about prior auth? In family practice we seem to spend inordinate time on it both at the initial notification/filing of as well as the front desk handling numerous angry calls from pts. Many times it is a medication pt has been on long term but insurance changed. Abruptly stopping a blood pressure medication can cause big problems, 911 and ER visits. Fangirl since Covid w you and ZDogg. Thanks for all you do to enlighten and inform.
As a pharmacist who works for insurance, specifically in the Medicare space, I can tell you that there are medical directors on board who sign off on criteria. It's also usually a medical director who sign off on appeals decisions. The insurance companies don't blindly make criteria. It's evidence based and, yes, you are correct. There are way more doctors prescribing things inappropriately than you think. And it's really Medicare who dictates these things. If we approve something that shouldn't have been approved, Medicare doesn't reimburse us and we end up losing money in that sense.
prior auth almost killed me. i don’t trust any of them
Thanks for your insight -- especially the "Whackadoodle" unproven remedies.
Insurance companies have found a way around ACA loss ratios. They bought out PBM's, so when they pay for prescriptions, they are paying themselves and skewing the ratios. That's why the "market" prices for drugs are insanely overinflated.
Excellent nuanced take on a complex topic. Out of control healthcare spending could bankrupt our entire nation.
Wow!! Didn’t know about the medical loss ratio under the affordable care act. Great info
Time to start a parallel system don’t you think? Many doctors are doing that already.
We saved a ton using Christian health share plans. Specifically SMI. The cash discount was usually 60-80%. $450/ month was our “share” for 7 of us.
And more gov control of healthcare would be more of this and worse.
As a pharmacist, I totally agree. My go to example which is a major headache, but reasonable are prior authorizations for certain opioid regimens (especially when oxycodone isn’t combined with buprenorphine). There may be a valid reason to do it, but there needs to be a plan to get the patient off of them quickly. With everything a provider has to deal with, it is too easy to just send in another prescription for a pain medication rather than the multiple conversations with the patient about how long term use will likely be more worse for the patient.
Ah... The prior authorization boondoggle. As a licensed acupuncturist, I've have long wanted U.S. healthcare to become cash-based, except for accidents and emergencies. When it comes to chronic health problems drugs and surgeries are rarely helpful and often hurtful. Rather, diet and lifestyle improvements combined with functional medicine modalities are the way to go. Currently in my 18th year of practice.
Thank you for your service
I am retired nurse and have been getting acupuncture for years. When I was working my insurance partially covered the cost,
Medicare only covers acupuncture for back problems which thankfully I don’t have. I found a wonderful acupuncturist who charges 45 dollars for a session for seniors. I see her once a week because that is discretionary spending that adds value to my life.
My “Prior” Authorization” for a cardiac catheterization was DENIED a WEEK after the procedure! It took reaching out to every level of approval to get it approved-unnecessary stress Aetna !!
Yeah, I had to live with those jokers too. I’ve got to the point where I would just refer to Aenta I’m not glad I met ya. That used to be their slogan for a while back in the 90s I think Aetna I’m glad I met you. I never spent so much time fighting with an insurance company in my life.
I wonder if all the illegals that have entered this country have to get prior authorization…..our healthcare system will fail its paying citizens by raising the rates to make up for their loss when they treat the illegals. Hardworking,honest,good American citizens will be strapped with another increase in insurance premiums because this government has allowed these illegals to enter our country…….not vetted, not vaccinated,carrying disease TB, scabies, lice ,bedbugs and God knows what else.
Regulation of insurance is what makes healthcare so expensive. Each individual should decide which treatments they wish to pay for based on personal risk assessment. Government should have no say except what is already covered by general fraud. Stop all government spending on healthcare, let the individual decide.
It certainly seems endless to our government…
Insurance artificially inflated costs to satisfy their economic incentive and policies. Medical insurance should be banned. Doctor and hospitals should be forced to operate by the economy of the general public they treat. Not regulated by the expense of corporate profit.
At Kaiser Permanente in Southern Calf the MDs get the treatment that is prescrobed
Somebody has to watch the costs. Doctors don't want to think about it. Patients don't want care to be constrained by money. Who do you want to be in control of spending?
I have High Deductible ($3000) Health Care. The promise of it is that patients will be incentivized to push back on excess costs and excess care. Storytime: I had a doctor order put me on AB and also order a tick-borne blood panel. The AB resolved the issue. The panel was negative. It cost (me) $560 after Cigna capped it. The doctor had NO IDEA it would cost that much. WHY NOT? She's looking at an internet connected computer. She has my Cigna account number. The contracts are in place and the costs are determined, but the doctor is not shown the cost.
What if the doctor saw that the test was going to cost $560 before she ordered it? She would have said, hmm, let's try the AB and if that doesn't work, we'll consider this expensive test.
Doctors need the tools to help patients understand the costs and the VALUE of tests.
I think the reason that Americans are so up in arms about this discussion and easily angered by it is because we have been getting the shaft for so long in terms of healthcare. We hear stories from England where they have the NHS and how there is such much less burocracy and red tape. We're spending more money on Healthcare than many other nations, and our life expectancy continues to decline. Americans are pissed at our politicians and the corporate interests that lobby them.
I remember going to the doctor before big insurance companies. A different experience.
My husband is a type II diabetic. He had success on trulicity a few years ago. He lost weight and was able to wean off all diabetic medication. We now have a child and have slowed down and his sugar and A1c have slowly crept back up. Our insurance is now denying trulicity ozempic and mounjaro which are due Eric medications. But my two friends who are in a weight loss program can get ozempic no problem. Make it make sense. I’m over here panicking with his hyperglycemia and insurance is giving out his medicine for vanity instead of to him who needs it.
It is unconscionable that in this day and age, and in one of the most wealthy countries in the world patients can die simply for not having enough money in their pocket. This is madness.
Dr P! Excellent content!
It is very alarming how big pharma, food and tech seem to keep us unhealthy and in need of their assistance!
6 year carnivore and all need for medicines are gone! Take your life back people!
Indeed, same here! If everyone ate purely real food (based mainly or wholly on animal products) I suspect the burden on health services would reduce by 80% and drugs by 95% or so. But we can’t have that of course because of the obscene profits made by big Pharma, some of which ends up in the hands of corrupt politicians and regulators.
Be sure and get your cancer screenings done
@@kathylong469cancer screenings?? The only one worthwhile is a pap test.
@@kathylong469 everything has improved and my wife and i are healthier than our young doctors/dentists! That's a good sign that things are just fine!
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Kathy Long👊❤️
PA are a pain for both the patients and doctors, however, what do you do about incompetent doctors, and ignorant people? Ex 1: 29 yr old diagnosed with thyroid cancer. Local surgeon 60 miles from Philadelphia said he could remove the tumor and then had no follow up with chemo or radiation therapy after the surgery. The tumor came back. Luckily, a friend told the son to go immedicately to a major cancer center in Philly! The outcome was very good after getting the right treatment. Ex 2: 56 year old women has pacreatic cancer with extensive mets to the rest of the body with a life expectancy of 6 months. The family opted to go ahead with radiation and chemo and I'm sure you know the outcome would the same. I think the medical community needs stop focusing solely on SAVING LIVES to the realistic outcome of EXTENDING LIFE PROBABLILTY. Extending life for an 18 year old is totally different than treating someone and 6 months to live.
YES MORE VIDEOS ABOUT THE INSURANCE MODEL AND TALK ABOUT THOSE DOCTORS WHO STEP OUTSIDE OF THE SYSTEM LIKE DIRECT PRIMARY CARE.. THANKS
Not much discussion or analysis of exactly what constitutes good “evidence”, in the medical community. Industry sponsored studies are absolute garbage.
The problem with "no prior authorization" (for example, in a PPO) is that an insurance denial coming months later into a recurring course of treatment can leave a patient/family on the hook for many thousands of dollars when an up-front denial would have given them a good chance to re-think the treatment options.
I take your point but why am I having to do prior auths on a 15 dollar medication for insomnia that has been around for 30 years?
The discussion always returns to the theme of overutilization in healthcare. The percentage of GDP spent in this sector will continue to ratchet up unless economic incentives are dissociated from medical education with a rigorous plan. The hard truth is that the policymakers are bought out and many don’t even know it.
My Medicare Part D actually changed my cardiologist’s prescription. Cigna prescribed for me, refusing outright the medicine my doctor prescribed. They said the two drugs were similar, not identical. The drug the insurance company wanted me to take is not available in doses that suit my small, sensitive and old body. I thought doctors prescribed and insurance companies did other work. I was wrong. I pay $80 a month for this coverage where the insurance company decides I have to take a larger dose of a different drug.
I agree with everything you said. But, I think that we should get a score. If your useless test ratio falls below a certain point, you don’t have to do PAs until your 6 month recalc. I rarely do expensive stuff because there are usually better options, but occ I need the expensive thing and then it’s just painful.
It's started here in Canada too.
I want Ubrelvy for migraines. Other Triptan meds don't work, which is what insurance required me to try first. Between my insurance company and the "requirements " needed (that have changed from one triptan, which I took, to another triptan) ,and my doctor's PA representative screwing it by either not doing anything or sending insufficient info up for MONTHS, I have waited over a year and still don't have PA. Ridiculous.
this is what RFK calls 'corporate capture' where industries take over their relative governmental agencies, in this case, health care being controlled by big pharma and the health insurance lobbies...
"Insurance companies always win." - Yours truly
Really appreciate you breaking that down. Wish we'd been able to keep right to try, still, though. I think that was a good, at the very least, temporary solution. Love ya! XOXO
Your right only use medicine with prior history. Not like we have ever found multiple uses for 1 medication….
WTAF?
I need a hip replacement but I’m too young and get hip injections to buy me some time. I completely understand that they have to watch the procedures but they take it too far and use the denial process routinely. Every time in my case and my doctors have to appeal. Causes me approximately a month of excruciating pain every 6 months. (I’m basically allergic to pain medication and only take it for actual surgeries). They have all the records, they know it works and yet they still play this game.
I've got universal care and like it way better because none of what you said applies to me. My system has resource constraints but it's accessible. It's awesome to have a system with few constraints but useless if the people who need it can't access it.
Doctor, why aren’t you uploading your videos to TikTok? Your videos are perfect for this platform because they feature you talking to the camera.