Like many Americans, I like a good medical drama. From our old friends on “House, M.D.” and “Grey’s Anatomy” to the new additions of “A Gifted Man” and “Hart of Dixie,” television is full of fictional providers that inspire us with their commitment to their patients and entertain us with their melodramatic personal lives.
What if our medical dramas reflected the reality of practicing medicine? Imagine if one hour of “House” featured 20 minutes of the good doctor and his staff filling out insurance forms, instead of miraculously saving his patients from rare illness. Or imagine if Dr. Altman spent her time calling the insurance company for clarification on a patient’s covered services, instead of pulling the heartstrings of patients and viewers alike.
Unfortunately, the drama of a true-life hospital or clinic, unlike its television counterpart, rests largely in paperwork, red tape and complicated forms. A key contributor to the flood of forms is the prior authorization form, to be filed by medical staff before medical treatment is given to the patient. It is a cost-containment mechanism to insulate insurance companies from paying for impractical or costly treatment. Each insurer has a different method of securing these prior authorizations and different forms to complete. L.A.’s community clinics navigate multiple insurers – all with different processes in place. This sea of paperwork costs a national average of $83,000 per physician each year, according to a recent Health Affairs study.
Not only do the hours of paperwork cost the physician more money, but some patients might feel the burden of the insurance cost-containment measures. According to a recent MarketWatch article, some private physicians have resorted to charging per form or flat rate fees for the loads of paperwork that accompany each patient visit. While this is by no means a typical method of recouping the cost, the prospect of passing even part of the cost on to any patient may stretch middle- and low-income patient dollars too far.
Consider not only the cost of filing paperwork, but the cost in hours, too. If prior authorization does not precede a given medical treatment, patients may wait days or weeks before they finally receive treatment or medication. In some instances, medications or procedures are simply denied causing great risk to the health of the patient. Filing a prior authorization form alone can take anywhere from 50 minutes to four weeks, according to an American Medical Association report that calls prior authorization forms an “intensely manual process” which is “extremely burdensome” and in dire need of streamlining. More troubling than that, a survey of doctors found that first-time prior authorizations were often handled by new hires with no medical experience. A recent report by the Mayo Clinic found that more residents spent an average of six hours a day documenting, including filing prior authorization forms, than spent an equal amount of time with their patients.
The hours spent filling out documents and explaining the need for an authorization to an untrained representative are hours that could be spent with the patients and their families. Those hours could be spent in diagnosis and treatment to mapping out a lifetime course of action for the betterment of a patient’s life. These are penalties to the patient far more precious than the cost management policies of insurance companies.
California has an opportunity to take a giant step towards fixing the dysfunctional prior authorization process. SB 866, a bill that has passed both the Senate and Assembly and is sitting on Gov. Brown’s desk, takes a few common-sense measures to streamline prior authorization and reduce delays in patient care.
First, the bill would reduce confusion and minimize time-consuming paperwork by requiring that all insurers use a short, standardized form for prior authorization requests – a step counted central to the America Medical Association’s recommendations. Crucially, it would also ensure that physicians have the option to transmit prior authorization forms to insurers electronically, cutting costs bypassing the antiquated paper forms completely. Finally, this legislation would require insurers to resolve prior authorization requests in a timely manner, automatically granting approval if insurers fail to respond to a physician within 48 hours.
The bureaucratic mess of prior authorization limits how quickly and effectively doctors can provide care. Streamlining ensures an authorization is in place so that every dollar spent, public or private, is utilized most carefully and allocated to the necessary and timely care of the patients. I urge Gov. Brown to sign SB 866 so doctors, nurses and other medical staff can get back to providing care and being our real-world heroes rather than wade through tedious forms.
Louise McCarthy is CEO of the Community Clinic Association of Los Angeles County.