Time is money, especially when it comes to approving medical procedures. And now a new statewide survey by the Georgia Association of Physician Assistants is stirring debate about the extent to which insurance protocols serve as harmful barriers to patient care or necessary cost controls. The findings also point to the promise of technology as a means of promoting better and more coordinated care.

The overwhelming majority of roughly 200 PAs polled (99%) said insurance company restrictions have altered their practice patterns; 94% feel that health plans frequently or occasionally delay or deny diagnostic testing or prescription medications, and 93% reported that authorizations, pre-certifications and step therapy had a negative impact on treatment.

“The lessons learned from this report are resounding, in that nearly all the physician assistants that responded to the survey cited major insurance hurdles they had to jump over before being able to provide the care they deemed appropriate for their patients,” according to GAPA President Mary Vacala. “Some cited several phone calls taking 45 minutes with an insurance company. Others noted that patients are forced to go without medication until the insurance company would approve the treatment already prescribed by the health care professional.”


Technology to the rescue?

Mindful that every hour devoted to administrative tasks comes at the expense of patient evaluations, she reported that many of the state’s more than 2,000 PAs have turned to technology in hopes of streamlining the process. For example, 64% of survey respondents used electronic medical records and 45% used e-prescribing on some level.

Health insurers also are tapping technology to speed up processes. Russell B. Childers, an Americus, Ga.-based life and health insurance broker for nearly 40 years and past president of the National Association of Health Underwriters, points out that UnitedHealthcare and Blue Cross Blue Shield of Georgia allow online approval of treatment in most cases — adding that these carriers serve most of the state’s health insurance market.
He also defends the use of industry protocols, suggesting they’re a small price to pay for ensuring that patients receive appropriate care. “When you look at the practical implementation of such controls and millions of dollars saved that are otherwise wasted in the service of a little time, it makes a lot of sense,” Childers explains. “Shouldn’t this system work better? Yes, it probably should. But it will only work better with the two sides understanding each others’ procedures.”

A contact of Childers who works for a health insurance carrier in Georgia told him “the underlying issue is that health care providers are naturally inclined to use the most powerful treatment or diagnostic test that is available, even when a less expensive alternative is appropriate.” As such, prior authorization, pre-certification and drug step therapy techniques are designed to block the overuse of medical testing and treatment. He admits that sometimes a less expensive generic drug isn’t a good choice, “which is the reason that insurers have a process to appeal the requirement. But the alternative would be a much more expensive system when the current system is already unaffordable for many individuals.”

GAPA also found that 20% of respondents said they, or a colleague, must deal with insurers 150 times or more each month to obtain approval for a prescribed course of treatment or determine the criteria for prior authorization or step therapy. Another 20% estimated their number of interactions to be between 61 and 100, while about 25% said it was between 21 and 60.

Most respondents believe in legislation to curtail insurance company restrictions placed on health care providers to improve the health of patients, with Vacala calling on the Georgia General Assembly to “take steps requiring that patient formulary information be more transparent and that there be a uniform electronic process for obtaining medication approval.”

When a client contacts Childers about any delays in the approval of a treatment plan, he says most of the ones that are longer than 24 hours “are caused by incomplete information that require follow-ups to obtain that information.” He usually can get them answers in a prompt manner, especially if it involves an emergency.

— Bruce Shutan is a freelance writer based in Los Angeles.

Register or login for access to this item and much more

All Employee Benefit Adviser content is archived after seven days.

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access