Malek: The governor should look at all the costs of prior authorization, and sign H.766

The Vermont Legislature passed a bill, H.766, that takes some preliminary steps in restricting prior authorization, a time-consuming process health insurers use to determine the medical necessity of tests and treatments doctors and other practitioners have ordered. Insurers do not speak to or examine the patients, and there are no standards for the credentials or training of those involved in the process. Insurers claim they are attempting to protect patients from being exposed to unnecessary care. But, of course, reducing expenditures is the primary motive.

The bill will now go to Gov. Scott, who will decide whether to sign the legislation into law. He will need to grapple with the question about how the legislation would impact health care in Vermont, especially health costs, which are a concern to all Vermonters. This concern was heightened when MVP estimated its premiums would rise 3% if the legislation were implemented, and BlueCross of Vermont put their estimate as high as 7%.

Rather than trust the figures provided by insurance company lobbyists, the governor's office should insist these insurance companies provide evidence for these suspiciously inflated estimates. Rather than adding to health costs, I believe enacting this legislation will substantially reduce health costs. I'd recommend the governor ask insurance lobbyists the following questions:

— If BlueCross is denying patients access to so many tests and medications that it would amount to 7% of its total costs, then such an outrageous denial rate should result in an investigation by the Vermont Department of Financial Regulation.

— How much are insurance companies spending on the various steps involved in prior authorization, including what they contract out? And when projecting savings from the denied tests, are they using the amount on the providers' bills, or the more appropriate smaller sum, the "contractual allowance." And can we assume they are also deducting the portion the patient would end up paying in deductibles and copays?

— How many prior authorization procedures did each insurer require last year, and what percent did each deny last year? Were alternative treatment plans suggested: If insurance companies believed they knew better than the treating clinician which tests were not needed, then they would surely know which other tests were needed for patients whose care was denied?

— Have insurers done follow-up on the outcomes and subsequent costs of patients whose care was denied?

— Do you know what the personnel costs of prior authorization are for the various providers with whom you contract? Is the cost especially high for primary care practices?

— Primary care practices divert what could be patient care hours into time contending with prior authorization requests. And they have to hire additional administrative employees to participate in the process. Do insurers have accurate estimates of what these increased costs are? Do insurers believe practices incorporate the cost of contending with prior authorization into the fees they charge? Have any insurers considered reimbursing providers for their costs of complying with prior authorization requests?

— To avoid contending with prior authorization, primary care providers often send patients from their offices to the ER, where prior authorization isn't required. Do insurers know how many unnecessary ER visits are happening to obviate the hassle the procedure imposes on clinicians, and how much these unnecessary visits cost?

— Do insurers believe their prior authorization processes contribute to provider burnout and turnover in primary care practices? How many primary care providers have insurers spoken with about their experiences with prior authorization?

I sincerely hope the legislators and governor will consider not merely the supposed savings, but also the many costs prior authorization generates. Primary care practice is an extraordinarily burdensome endeavor, and most primary care clinicians work two to three hours every day beyond scheduled patient hours, as well as weekends.

Some of this time is built into the work. This is not the case with prior authorization. The time spent on prior authorization is a completely gratuitous imposition, one that every provider resents. If Vermont enacts this legislation, it will represent a solid first step in saying to primary care clinicians working in Vermont, and those considering relocating here, that Vermont cares about you.

Marvin Malek is an internist who lives in Berlin.