Who Actually Is Reviewing All Those Preauthorization Requests?
Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting.
Don’t worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do.
However, the audience was a bit unusual for me. Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care. I guess that explains why they had time in the middle of the day for an hour-long presentation.
I gave my talk, but there were no questions.
I had a few moments afterwards to speak to my audience. Since the physicians were not involved in patient care, I wondered why they wanted to hear a talk about new advances in heart failure.
The response surprised me: “We no longer care for patients, but we care about what’s going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures.”
My jaw dropped: “I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients?” The answer was yes.
I was really curious now. “So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities?”
Their answer hit me hard. “Oh, we’ve heard about those drugs before. We’re asked to approve their use for patients all the time. But we don’t approve most of the requests. Nearly all of them are outside of the guidelines that we are given.”
I stammered. “I just showed you evidence that these new drugs and devices make a real positive difference in people’s lives. People who get them feel better and live longer.”
The physicians agreed. “Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again.”
I was astonished. “If the drugs will help people, how can you say no?”
Then I got the answer I did not expect. “You see, if it weren’t for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn’t a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare.”
I responded quickly. “But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren’t getting the drugs that they need.”
One physician looked at me as if I were from a different planet. “You really don’t understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare.”
Before I had a chance to respond, he continued: “Plus, if I approve too many expensive drugs