Part of living with cancer in the US:
Prior Authorizations: Part of living... - Advanced Prostate...
Prior Authorizations
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Tall_Allen
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73 Replies
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Waiting for prior authorization to watch video😄
in reply to SPEEDYX
😂😂
Then again
There is no shortage of crazy, irrational, unfounded and delusional treatment regimes many patients would be inclined to use with enabling docs.
Especially if subsidized by insurance money.
This is counterbalanced by the bad faith exercised by insurers in imposing restraints on treatment.
For them it's always about the money, not the science. Only what the science can excusably justify.
I think there are irresponsible bad actors on both sides of this table.
Could be, Cesces, but one side has nothing to lose and the other has everything to lose.
Actually, neither side sees that they have anything to lose.
Patient - No harm in asking. 88 year old grampa is on a ventilator about to die. No harm in asking the insurance company to pay $100k per week to extend his life a few weeks.
Insurance company - No harm in refusing. What we save is 100 percent margin. Drops right to the bottom line. We will pay for small stuff like office visits and lab tests. But anything big, it's cheaper to fight and delay than to pay. We have a whole department that can handle these disputes on a production line. We make money even on the delay. We never have to wait on the phone line, they do. That's how we ration care to those expensive patients that have the temerity to actually use their coverage.
Isn’t it TRUE !!Insurance Companies are absolutely practicing Medicine without a License!!!!!!
in reply to Spyder54
Insurance companies employ many doctors so Don't think that statement is true.
monte1111 in reply to
Sure they do. Dr. Strangelove, Dr. Kevorkian, and, of course, Doctor No.
in reply to monte1111
You forget Dr. Vinnie Boombatz.America's doctor.
monte1111 in reply to
I wonder how Rodney is doing these days.
in reply to monte1111
Let me check youtube...I think he's on Johnny Carson tonight
Gabby643 in reply to
Indeed
TomTom, my memory is fading fast, but, aren't you a Witch Doctor? If not, forgive me; If yes, I beg for mercy. Lots of Witch Doctors here.
in reply to monte1111
Witch Doctor...no but I know a Dr. Witch...
Tall_Allen in reply to
They only use consulting doctors when their decisions are appealed. Even then, they are usually retired doctors who have not kept up with innovations.
When we thought my husband’s cancer had spread beyond his prostate, we were trying to get a bone scan approved. The insurance denied it and we kept appealing. Finally the insurance had a peer to peer between my husband’s oncologist and an insurance doctor. The insurance doctor was pediatric doctor! We were so mad! (And it was denied again!)
Luckily, we found a study at Stanford using gallium (sp?) and yes, the cancer had spread all over. How long would my husband’s treatment been delayed if his oncologist could only go by the MRI and CT scans?
Vangogh1961 in reply to
I requested information on the committee to place meds on formulary and was informed they couldn't provide or confirm an oncologist was on the committee.
Of course not
Technically, all they are doing is interpreting their coverage provisions.
You decide what care you get.
They decide whether they pay for it or you do.
This will continue as status quo so long as old angry men keep voting for mean angry politicians. (that's the demographic keeping this in place)
It would be so easy to fix with some small changes in the law
Mostly UR is done by nurses and only forwarded if appealed or conclusion is unsure. (I did UR for a couple years.)
in reply to Vangogh1961
UR?
Boywonder56 in reply to
He cant hear u ....
in reply to Boywonder56
r
Boywonder56 in reply to
His screenname is vangogh....was playing on the artis cut of his ear.....trying to humor the atomospher...j.o.h.n. is mia
in reply to Boywonder56
Good one..missed that completely. J-o-h-n would be proud.
Nicely done.
Turt713171 in reply to
Utilization review
Do you think they attended this week's ASCO conference? Some patients I worked with had their SBRT claims denied because their insurance company hadn't kept pace with innovations, even though it would have saved them money.
You will get further if you refrain from ad hominem remarks that only show that you don't have anything worth saying about the subject.
Dr. Glaucomflecken argued they were practicing medicine without a license, not I, although I see his point. I guess you have never been refused by insurance for a vital therapy, or you wouldn't be so laissez-faire about it. Good for you. Some of us haven't been as lucky.
FWIW, here's what a doctor wrote in his response to this video:
"Me: orders MRI for a patient with glioblastoma
Insurer: denied it, because they would have covered it if the patient had brain cancer
Actual reply to my appeal:
“How was I supposed to know that is a type of brain cancer?”
Interesting video. When Canada introduced universal, government run health care in the 1950s and 60s, there was tremendous resistance by medical professionals and some members of the public. While our system is far from perfect, there are not many Canadians who would exchange it for the American system and that includes all of the doctors and medical professionals I know.
I agree. It seems like every civilized country except the US has free universal health care, and it works very well.
in reply to MarkBC
Is the author wrong? Have things changed?
city-journal.org/html/ugly-...
maley2711 in reply to
Does a good job of reminding us that there are 2 sides to the story/debate. Is it a good idea to have a governmental monopoly over a critical service? Do average income citizens fare better with one system when compared to the other system? Right now, at least in my state, if I don't like my insurer's decision, I can appeal to a state review board. When the government is the insurer, to whom do I appeal the government's decision?
I'm guessing that there is actually no "best" system. Each has weaknesses?? And finding a set of facts on which all sides can agree may be impossible?? If the stories of long waiting lines in more socialized medical systems are true, why aren't more citizens demanding change? Or are they? More money should result in shorter wait times...at least it seems so? so many things could be discussed!!
It’s ironic that I buy drugs from a BC pharmacy at considerably reduced prices. what happened to the drug price reforms in US ?
That got started by Trump but I don't know if it is still being pursued by the Bidden administration. Hopefully it is.
How about Dr. Pepper folks?
it got bought out by snapple .....ruined it
I know I'll get flamed here, but,,,IMO, the prior authorization requirement and process makes sense. But like so many things for which one basic process must cover a myriad of different scenarios, there will be some unintended consequences and unfair results.
Consider the following hypothetical:
We are all paying our own health insurance bills (like I did before I qualified for Medicare).
I partner with an unscrupulous radiologist, borrow some money, buy an MRI machine, and open an imagining center. My ad reads: "Sometimes got a back pain? Come get a full spine MRI. No cost to you, your insurance will pay." If it weren't for the prior authorization process, I'd make a killing. And if I franchised my business, your already-high insurance premiums would go up.
In some sense, you are describing the basic business model of medical care in the US, when looked at from a corporate point of view: provide the maximal amount of the most expensive services that might be deemed "appropriate" by the third-party payer even if they are not urgently needed or indicated.
Third-party payer systems invite this. As a business, if doing "xyz" bring greater profits and doing "xyz" goes unchallenged by either patient or payer, why on earth would you NOT increase your "xyz" procedures if you can justify them on paper? (And of course justifying them on paper does not mean they are always truly needed, let alone the best of various other options.)
My wife works at an HCA hospital, so she sees this as a matter of course, and is convinced that management condones and even demands (as policy) that departments err on the side of excessive and/or more expensive tests and treatments. HCA of course has a nice history of that already... the theory by some is, they still do it but are less blatant about it (since taking TOO MANY cookies from the cookie jar at one time is a sure way to get busted).
Prior authorization is supposedly a check on this, but it certainly does not apply to emergency and trauma scenarios. How would we think the huge payouts for CEOs and other managers in the healthcare biz come about? By trying to save the third-party payers every possible penny, LOL?
There is a dividing line - standard-of-care (SOC). One can quibble about whether a SOC is really standard, but in the US, there are mainly 3 organizations (for prostate cancer) that do a good job of defining the standard - NCCN, ASCO, and AUA/ASTRO/SUO. There are others as well. The following article, which is focussed on SBRT, explains the issues:
prostatecancer.news/2016/08...
So, if a doctor wants to do anything within those SOC guidelines, insurance companies should not get involved and should not require pre-authorization.
But what if a doctor wants to do something for a very sick patient that is outside of such guidelines? Let's say there is a costly procedure that has only a 10% chance of working, and even if it does work, it will probably only add a couple of months to survival. Should insurance cover it? And, understanding that time is probably of the essence, what is an ethical procedure for dealing with such cases?
I have noticed that insurance companies seem to defer to well-known oncologists (another reason to work with a top oncologist), I have been pleasantly surprised a few times when a top oncologist gets pre-authorization for medications outside of FDA-approved indications. But what if your MO is Joe Shmo out in the boonies?
I assume this results because the insurance company authorization application reviewer is comfortable accepting the word of well-known Dr. Top Oncologist, but not the word of unknown Dr. Joe Shmo. Dr. Shmo's application would need a more detailed review, and it might be easier and less expensive for the insurance company to simply deny it.
At the risk of getting too far afield: Another problem is that, if Dr. Top Oncologist works for a big health care organization (e.g., Sutter in my area) and Dr. Shmo is a private practice, the insurance company pays Dr. Top Oncologist's organization more than they pay Dr. Shmo for exactly the same service, procedure, or test. This is because contract negotiations between insurance companies and big providers is basically mutual extortion. Provider to insurance: "Do you want to tell all your policy holders that they can't access any of our 500 doctors?" Insurance to provider: "We cover all of Wombat Enterprises's 5,000 employees. Do you want access to them." Dr. Shmo has near zero negotiating chop.
If you have a good understanding of this field, please let me know if I have my facts scrambled.
In Denmark, we do it differently. It's all free, but you pay 50%+ in income tax instead 🙂
Same in Norway (though I pay 31% income tax). A few years ago I had a pregnancy situation that involved different hospitals and many doctors, tests and procedures. I never paid a penny, never saw a bill, got plane tickets and appointment messages on my phone, and everything was seamless and the care I got was amazing. When that storm was over and I realised how much had been done for me without me even having to lift a finger, I promised that I would never ever complain about paying taxes.
Norway has a population of about 5 million with a sovereign wealth fund (from oil) of over $1 trillion. That's a rather unique situation.
Of course, but many other countries manage to make it work with larger populations and no oil wealth fund. And we only use a a small percentage of this every year to cover any deficit in the budget. Over 80% is covered by just taxes. And then other forms of income covers the rest. But obviously we have extra financial security because of it.
Let me give you a real world example. Last December (6 months ago) the FDA approved PSMA tests. Virtually every dr in the field has known for years they see mets years sooner than current Conventional scans do. Yet as of today most insurance companies will still not pay for them. Almost everyone here has fought with an insurance company one time or another to get them to pay for a treatment that has been proven to extend their lives. They’ve also likely fought to get paid on home or car damage they were due. We were all getting a laugh at that pain whether based on a literal or perceived situation. Why on earth are you expending so much energy to defend them? Do you work in the industry or do you just get pleasure busting peoples balls?
Schwah
I have thought a lot about this new ability to detect previously undetectable metastases far earlier, in men who were thought to be "non-metastatic." The insurers would not only pay more for these scans, but it would open the door to having to pay for earlier and more aggressive (= expensive) treatments for all these men!
An alternative to these scans was proposed by some doctors may decades before the scans were developed: if you have very high PSA and/or Gleason, just go ahead and assume your cancer has spread to the bone, whether that spread is detectable or not, and treat accordingly. In other words, prioritize systemic treatment (over local) from day one since high-PSA/high-Gleason PC is an intrinsically systemic disease.
This was the approach I favored even before my mets were detected. Further, I have no interest in more advanced scans to track my PC progression or regression until I am sure that such scans will impact my choice of treatment. So for example, I have just started ADT and will stay on only that until PSA rises or I become symptomatic. Why do I truly need scans to know how well the ADT is working, so long as my PSA is suppressed? I already know I want to do early chemo about six months into ADT, and hold off on trying to radiate the mets until later.
My high ALP is telling me I have mets, but I frankly don't yet care to see exactly how much better or worse they are compared to late 2019 until I know ADT and chemo have failed. That's just me, of course, but unless the info is something I plan to use to change my immediate treatment course, that info is just another source of stress. Out of sight, out of mind, so long as symptoms and pain do not exist.
That gets to a somewhat different matter - the FDA approval process. In that case, the FDA would not approve PSMA PET scans until there was proof from prospective trials that PSMA PET could significantly change treatment decisions. Once that data was in, the FDA approved it. Usually, CMS and insurance follow FDA approval, but it is not automatic. I have heard that a few major insurance companies are already approving it - I haven't heard if CMS (Medicare) is. Should it be automatic? In the UK, they have 2 separate agencies that allow new drugs. NHS (like the FDA) goes over the research and says whether the drug is effective and safe. NICE then decides whether they will allow the new drug to be covered. They use a cost/effectiveness analysis and consider whether good alternatives are available.
Just starting Medicare. Does it require prior authorization?
It depends. If you have Medicare Advantage, you might have more prior authorization required. What is good about Medicare is you can see what the rules are or call to find out. Ps if you have Part D for your prescriptions drugs, many of the expensive ones do require authorization.
I do not have Medicare Advantage. I have a Plan G supplement with United Health and a Plan D dug plan with Humana.
How about with injections of Lupron that are covered by Medicare Part B? Surely someone at Medicare looks over the doc's shoulder.
Lupron is covered in plan d copU 168.00
Part B. ( part D covers pills)
Yes that's what I understand
Medicare has National Coverage decisions as well as billing guidelines. In the absence of National rules, there are local ones. You can read all these on cms.gov/. Part d for pills is separate but info is available too.
I don’t mind considering the hypothetical, but unfortunately I also consider the actual experiences I had with prior authorization nightmares.
To cite but one example, I was to get a MRI guided biopsy a few years ago. My insurance denied the MRI via a lengthy letter explaining that they would cover it AFTER a biopsy but not before.
Their justification was very specific. It was also clearly based in outdated information.
My urologist was completely unsurprised by this and suggested I pay for it myself if I could afford it, which I did.
I could go on but I think I’ll leave it be and start my day instead.
I requested a test, was given 10 year old studies to show why it wasn't needed. No results since 2009 were in the rationale to deny.
I guess these bleeped out remarks will elude us
The only good thing I'll say about the insurance industry is that they serve as a counter-balance to the pharmaceutical industry. A specific example: The insurance industry is funding a study to determine if Xgeva every 12 weeks is as effective as Xgeva every 4 weeks. Interim results didn't talk about effectiveness, but said that side effects were significantly lower in the 12 week group.
I forget the exact term, but the insurance company was also behind the stoppage of what I will call "extreme chemo". Normally bone marrow is the limiting factor in chemo dosing, so the theory went that if you harvested and saved marrow from a cancer patient, then you could blast them with mega doses of chemo that would kill all the cancer and the marrow along with it, then transplant the healthy marrow back into the patient. Very expensive for insurance and very painful for the patient, and when the insurance companies funded a study they found there was not medical benefit to such an extreme procedure so it isn't done anymore. My oncologist told me this story, as he was in the early days of his career way back when this was going on, and he never felt good doing it to his patients, and he and a number of other doctors were quite relieved when it was proven worthless.
Ah yes, PA Hell. Because, ya know, "shareholder value" is more important than human lives!
The California Senate has recently introduced a bill prohibiting hospital administrators from (essentially) practicing medicine. One tiny step towards reducing the influence of non-medical professionals in patient care...
"SEC. 2. Section 2057 is added to the Business and Professions Code, to read:
"2057. (a) A health facility licensed pursuant to Section 1265 of the Health and Safety Code is prohibited from requiring a physician or surgeon licensed pursuant to this chapter, as a condition of obtaining or maintaining clinical privileges, to agree to comply with criteria, rules, regulations, or other policies or procedures that are not knowingly and explicitly ratified, issued, or promulgated by the medical staff, that directly or indirectly prohibit, limit, or restrict the ability of the physician or surgeon to provide a particular medical treatment or service that falls within the scope of their privileges, or from requiring a physician or surgeon to obtain permission from a nonphysician or nonsurgeon to perform a particular medical treatment or service for which consent has been obtained from the patient or the patient’s representative, except as provided in paragraph (b) or (c).
"(b) If a physician or surgeon, exercising their independent professional judgment, determines that a particular medical service or treatment is medically appropriate, a health facility shall not limit or otherwise exercise control over their independent professional judgment concerning the practice of medicine or the diagnosis or treatment of disease unless either of the following applies..."
During my many years of travel in the USA for business, I encountered many colleagues and co- travelers, who disparaged the socialized medical system that Canada has. I raised a family of two in Canada and have been treated for PCa since 2016 - I can honestly say that I am very satisfied with the level of care my family and I have received. Not once did I have to worry whether care would be provided and whether I could afford it. The US military and government workers are all provided the equivalent of socialized medicine. - if good enough for them, then why not the rest of the country. Socialized or non-profit based medicine is cost effective and finally mortality rates are lower in non profit systems. Cheers, Phil
I got very sick in a small city in Mexico. I was taken to a local hospital that looked very run down compared to any hospital I've seen in the U.S. But the people were kind and knowledgeable and did well for me. When I asked them how much I owed them they said I owed nothing. I was over 65 and covered, even though I wasn't a Mexican citizen.
I was damned impressed.
Alan
The same happened to my family when we visited St. Lucia. We had a car accident and stitches were required by my sister-in-law to close a gash on her forehead. She was treated at a local clinic and there was no payment required. Pills included. Cheers, Phil
Yeah, I expect the FDA's approval of aducanumab will lead to much merriment.
This is clearly a topic of high interest to people like us whose lives are deeply involved in issues of medical care and financing. The issues involved are complex and contradictory. What is best is different for:
Sick vs. healthy people.
Young vs. old people.
People with rare diseases vs. people with common ones.
People needing cheap treatments vs. people needing expensive ones.
Wealthy vs. poor people.
People who use insurance vs. those who pay for but rarely use it.
People who profit from medical care vs. people who pay for it.
The solutions that work best for some people are often terrible for others.
What I believe that we have to do is to put the decision making powers in the hands of people a) with high expertise, b) without personal financial interest in the solutions, c) with great experience in the various aspects of medicine from drug development, to treatment, to hospital administration, to large scale financial management, and so on. They should be charged with finding the optimum balance between maximizing health care benefit and minimizing cost, producing the greatest good for the greatest number and the least harm to all. We have to take decision making powers out of the hands of drug companies, for-profit hospitals, and for-profit insurance companies. We need some wiggle room for the for-profit institutions because they can serve people who fall outside the common parameters, they can innovate, and they can keep the bureaucrats honest. But they shouldn't be allowed to dominate national health policy as they now do.
In the past, the U.S. has led the world in some areas, especially the Food and Drug Administration, but we have since fallen way behind all of the other economically advanced countries.
We can and should do better.
Do you favor the UK model (NICE)?
I'm not an expert at any of this and I haven't personally experienced health care in the UK. However, given that the UK has better health outcomes than the US, and at costs which are only a little over half that in the US, I have to favor the whole UK package of NHS and NICE over the relatively chaotic and very expensive system that we have here. In addition, the idea of getting healthcare with much less of the sudden expense, stress, and hassle of battling insurance companies and providers as we do in the US is very appealing.
For the last 37 years I've gotten my own healthcare from the Kaiser Permanente HMO. The last 10 of those years have been on Medicare. It's a system that, I imagine, is significantly closer to what I'd get in the UK than working with for profit insurance systems in the US. I considered switching from Kaiser to another insurance company a couple of years after my cancer treatment and was told by agents that they'd send me papers to fill out if I wished but my chances of being accepted were very low because of my cancer treatment. That was an eye opener. The care at Kaiser has been generally good. I can't rely on them always doing the best thing but, after all, they're human beings.
If NHS and NICE are like that, I'd vote for their method.
Here's an interesting article written from a single patient's point of view: cnn.com/2019/08/07/opinions...
Alan
Good historical background, thanks. Someone is going to make the decision as to whether a treatment is cost-effective - either a private for-profit insurance company based on non-discoverable internal memos or a governmental agency that will publish a transparent analysis of their findings and usually have an open comment period. I may not like or agree with the governmental agency's analysis, but at least I will get to see it, comment on it, lobby my congressman about it, and their motives aren't as questionable. Either way, there are going to be what has been labelled "death panels." I would prefer the "death panel" be at a government agency.
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