NM providers fault insurance red tape for cutting into patient care

Health insurance-related tasks are so time-intensive and complex that many clinicians and claims processors in New Mexico are blaming them for compromising patient care and driving health care workers out of the field, according to the authors of a forthcoming study commissioned by the state Legislative Council Service.

Doctors and nurses reported spending at least three to four hours per week on billing tasks, according to the report produced by two researchers at the University of New Mexico Center for Social Policy. The pair is set to present the report Tuesday during a legislative meeting.

Center for Social Policy Executive Director Gabriel Sanchez and Research Assistant Professor Melanie Sonntag in May and June conducted focus groups and interviews with 31 clinicians and other workers who determine whether insurance will cover care, Sonntag told Source NM.

Participants, who are not identified by their names or workplaces in the study, told the researchers a lot of their time is wasted by prior authorization, which is when a health care provider must get permission from an insurance company before either seeing a patient or administering a treatment, Sonntag said in an interview on Tuesday.

A clinician who participated in the study told Sonntag they spend up to half of their time with each patient just doing documentation and prior authorization, she said. Another physician in emergency medicine told her they try to see as many patients as possible and use their time outside clinical hours to handle billing and insurance tasks, which others have warned will burn them out.

"This is time that could be spent with patients," Sonntag said. "It's really frustrating for patients and clinicians that they can't spend that much time with patients to address their health concerns and are instead spending a lot of time on these administrative tasks."

Sanchez and Sonntag concluded that there needs to be deep structural change to ensure that people can receive proper health care and that clinicians don't get burnt out and leave, she said.

"The discussions we had with healthcare professionals suggest that the system is in need of significant revision that may not be possible without considering moving to another model," they wrote in the study, according to a news release last week from the Health Security for New Mexicans Campaign, a group that advocates for affordable health care.

Sonntag said one structural change she thinks makes sense would be the campaign's proposal called the Health Security Act, which would provide health insurance for about 1.8 million of New Mexico's 2 million residents, or everyone except for federal retirees and members of the military. Under the proposal, the insurance pool would be funded by the premiums workers and employers already pay to private insurance companies.

"They're really trying to design something that works for our state, and we know New Mexico has our own challenges and ways we like to address things," Sonntag said.

That legislation was most recently introduced to the Legislature in 2019 but didn't pass. Another bill that would have tasked the state Office of the Superintendent of Insurance with studying the issue also died in 2022.

The idea has met opposition at the Roundhouse from the state chapter of the National Association of Benefits and Insurance Professionals. Proponents of the legislation have included the New Mexico Medical Society, the professional organization for physicians in the state. Source NM sent requests for comment to both organizations and will update this story as needed.

It's already well-documented that the United States spends an increasing amount of money on administrative tasks in health care, and more on health care overall than comparable countries, Sonntag said. But the upcoming study illuminates how prior authorizations and the billing cycle make it even more difficult for health care providers in rural areas to care for patients when they're already dealing with insurance companies denying claims because people are "out-of-network."

The two researchers are slated to present their findings to the interim Legislative Health and Human Services Committee in Gallup on Aug. 19. Legislative committee meetings between sessions can sometimes, but not always, lead to a lawmaker introducing a specific legislation proposal.

"This is like every academic's dream but I'm hoping to accomplish system-level change," Sonntag said about the study. "I think it would be amazing to really reform the system to make sure that health care can be patient-centered."

This story was originally published in Source New Mexico.