The pre-authorization process is not to deny needed health care, but to ensure the provision of evidence-based care and avoid the potential for costly out-of-pocket medical bills, medical complications and subsequent procedures.
By Dr. Adam Solomon, Special to CalMatters
Dr. Adam Solomon is the chief medical officer for the MemorialCare Medical Foundation, a physician-run health care organization.
All Californians deserve a health system that consistently provides high-quality, affordable care. Unfortunately, legislators in Sacramento are considering a bill that, if passed, would do just the opposite: It would be a prescription for low-value care that would harm patients both financially and physically.
Senate Bill 250 dismantles prior authorization, a tool used in limited circumstances to ensure patients receive safe, high-quality, affordable health care that is in line with best practices. The goal is not to deny needed care, but to ensure the provision of evidence-based care.
You might assume that when a doctor tells you that you need a procedure, it really needs to be done, but the data show that in a single year, between 24% and 42% of Medicare beneficiaries received one of 26 tests or treatments that scientific and professional organizations consistently have determined to have no benefit or to be outright harmful. This is the reason certain services undergo a pre-authorization process.
I have witnessed the variation in the way patients are treated by specialists, both as a practicing internist as well as in my position as a chief medical officer. I want to clear up some common misconceptions about prior authorization.
First, there is a strict and specific time limit that organizations have for these authorization requests to be reviewed. Those turnaround times are regularly audited, carefully monitored, and need to be reported at least biannually, with some plans auditing us monthly. For my organization, which processes around 750,000 requests per year, one-third are approved in under one day and, on average, in less than 2.5 days.
Prior authorization rarely causes delays, and the number of denials is very, very low. In most cases, they are limited to specific procedures that have been found to be of marginal value to the patient or that catch a referral to a provider or location that is not in the network, saving the patient unnecessary out-of-network costs.
Pre-authorization fulfills an important function in American health care. Just as you would expect the pharmacist to catch an errant prescription with the wrong strength or that caused you an allergic reaction in the past, prior authorization provides a second look to confirm that the service being requested matches the evidence.
It can also protect patients against surprise billing for out-of-network charges. SB 250 would not allow this check-and-balance in favor of patients. Any request for service must automatically be honored by the health plan, medical group and the patient.
I want to underscore the value of oversight of a network of physicians through the pre-authorization process. There are more than 3 million new clinical studies published each year in countless medical journals. No single doctor can keep up with the sheer volume of change. Having the oversight of an entire network of doctors allows our organization to look for outliers in prescribing and referral patterns and address efficiency issues.
Remember that 40% of all health care in America has often been found to be duplicative and unnecessary. Policymakers say the physician’s “power of the pen” drives 80% of the cost of health care in America. Physicians don’t always consider the cost of those decisions.
As physicians, we need to be accountable to both our patients and the overall effects on the cost of health care. We all want to improve the health care Californians receive. As policymakers look for ways to make health care more affordable without harming its quality, unleashing cascades of unnecessary care is not the answer. SB 250 is bad medicine for California.
Read an opposing viewpoint on this topic here.