Why Doctors Can’t Have Nice Things
A lot of practices engage in the perpetual search for “Revenue Enhancement.” This means they are constantly searching for things to do that earn more money than simply seeing patients and providing the usual care.
A few years ago, it became evident that every Cardiology group in our town has expanded into the field of more vascular testing and procedures. On the surface, this makes sense. Coronary Artery Disease is a marker for other vascular diseases, particularly in the carotids and extremities.
Thus, every human who walks into a Cardiologist’s office has now been getting Carotid Ultrasounds and other vascular testing done in the Cardiology practice. These are being done every six to twelve months, depending on how normal or abnormal the study appears. Since no one appears to be totally normal, it serves as a basis to do them more frequently. All it needs is one visit and the patient becomes a regular customer for life of questionable vascular studies, frequent echocardiograms, and annual stress tests, regardless of the need for such frequent testing.
If you read the reports, you see things like “Moderate Disease of 1-49% occlusion.” That’s an impressively huge range which includes people with normal carotids suddenly being called “moderate disease,” thus warranting repeated surveillance and significant expense.
To put it simply, Cardiology has stumbled into another big stream of revenue. All of this comes from somewhere. Either patients with high deductibles get a big bill or the insurance companies suddenly notice money flowing out in unexpected directions.
Worse, a lot of it is being done in a manner that actually causes a potential for patient harm.
Consider elderly patients with borderline kidney function. Are they at risk for vascular disease? Yes. But, the ordering practitioners, who are often NOT physicians, keep failing to ask the important next question: “What if this test is abnormal? Will we do something that will harm the patient? Will we follow the path to iodinated contrast studies and stenting in a patient with a creatinine of 1.9, fixing some of the blockages, but now condemning the patient to a life on dialysis?”Let’s get back to the expensive part. The practices are very good at convincing almost all of their patients that such annual testing is vital to their survival.
So, we have a clear identifiable case of excessive testing at excessive risk and excessive expense. If I am noticing it, you can be darned sure the insurance companies are aware of this.
You can scream about the insurance companies all you want… and I do it myself on a daily basis. However, the basic principle of health insurance is everyone pays a predictable amount into a pool and that pool then pays for the unexpected medical costs that we all will eventually face. Yes, the companies take out their own obscene profits, but the principle of “how it works,” remains the same. If you crank up the costs, either with tons of unnecessary expensive tests or ridiculous drug costs, there must be a response for the company managing the pool. If the advisors to the company add the extra comment, “These are also not helping anyone and are probably hurting some,” get ready for a response.
This week, we witnessed the response from one of the largest health insurance companies in our state.
In the past, certain tests always required prior authorization. These are CT scans and MRI scans. On the other hand, tests like ultrasounds have almost never required prior authorization. For many years, this has been the standard.
In particular, carotid ultrasounds have never needed prior authorization in our region. NEVER!.
Well, guess what. The state’s largest health plan now requires prior authorization for all carotid ultrasounds and any vascular testing. And… let me tell you… the hurdles to getting these tests are not trivial. Worse, the ordering practices are coming to us, demanding we do the prior authorization for tests we never ordered or performed, including tests done many weeks ago. The first couple of such tests, we made the effort (Yes, sometimes we are too nice and take the meaning of PCP too seriously!), but failed on the appeal.
War has been declared. The obvious target is practices doing their own excessive vascular testing. Unfortunately, the tool is a sledge hammer which is hurting us all
.Do not call me an insurance company apologist, but in this case, you have to say: “Can you blame them?”
I wrote about this issue from a different angle earlier this year. This is why we can’t have nice things. As bad as medical practice feels, we doctors still keep doing things that only make it worse.
Insurers could easily identify those practices that perform and bill for the scans in-house, and make them the only ones required to go through the pre-auth headache.
Agree with all your comments. One question: I thought you had retired from practice and closed your Concierge Care Office yet you wrote “The first couple of such tests, we made the effort (Yes, sometimes we are too nice and take the meaning of PCP too seriously!), but failed on the appeal.” Are you back in the trenches practicing Medicine again with the rest of us?
One of the senior insurance physicians I worked with asserted that prior authorization in and of itself cut requests for a particular test by thirty percent.