RE: Does prior authorization really save health care dollars?

[Guest guest]

Gordon,

I couldn’t agree more. Example: In

this area, many of the PPOs now require prior auth

for all CT scans. The other day, I had a patient come in with nonspecific

abdominal pain but he is someone who NEVER complains about anything. I was

worried enough that I wanted to get a CT. Of course it was a Wednesday (my

nurse is off), so I had to spend 30 minutes with the insurance company getting

the proper paperwork done. He had the CT which showed a ruptured appendix. So

what would have happened if I didn’t have the 30 minutes? Would I have

just decided to do watchful waiting? Would the patient have died of

peritonitis?

I firmly believe putting up barriers to

care ends up costing way more money than it would ever save. Even worse, the

insurance company never assumes responsibility for the bad outcomes incurred by

the barriers. This remains one of the most challenging problems I see in our

current medical system.

Does prior authorization really save health care dollars?

I suspect that the net effect of prior auth is to

actually increase health care costs, but by shifting much of that cost to

office practices where it is difficult to track.

Here's a real life scenario from today:

A patient of mine is in a fix. Her insurance company is suddenly

requiring prior authorization for her Nexium. The insurance company wants

to save money - a good goal, but will this policy have the intended effect?

Because the insurance company is asking for information about how she started

this medicine and I don't have the details, I asked her to fill me in on how

she ended up with this medicine.

Her response via email:

" Regarding

the Nexium, I have only taken Prevacid starting at 15mg, was still having sharp

pain in the throat so Prevacid was increased to 30mg. I was on that for a while

.... I was still having pain and flare ups then we changed to Nexium 40mg

(ironically because the insurance would not cover the Prevacid) I don't know if

this makes sense, but the change to Nexium, turned out to work better. The pain

was better and the flare ups have been much less. I don't know what else would

work...guess I'll let you figure that out. I hate the thought of changing

something that is working! "

So now I will send this off to her insurance company to see if they will

agree. If not I may have to send her to a gastroenterologist who will

have to document via upper endoscopy her continued need for the medication.

As an attempt to help reduce health care costs, I see only increase costs to

this practice for the amount of time spent by various staff, and an increase in

health care expenditures for a consultation and then procedure that might not

have been necessary, and all of this might be because the insurance company has

negotiated a better kickback from a different pharmarmaceutical maker this year

and wants to drive market share in their direction.

L. Gordon MD

[Guest guest]

Gordon,

Agree completely.

How did all these folks squeeze their way into the sacred

patient/physician relationship?

Layers upon layers of regulation and " self-fulfilling

bureacracy " $$$$$ and then we work harder to pay for all

these people to micromanage us to death and to

the ultimate detriment of our patients.

If we suddenly woke up in the middle of the night and

discovered our CPA and insurance agent, plumber,

electrician, and techie guy in bed between ourselves and

our spouse we would wonder...

" how did these people insert themselves into this sacred union? "

and then we'd call the police.

We need to take back our profession.

Thanks for all you do Gordon. I quote you frequently!

Keep compiling the data....

" You never change things by fighting the existing reality.

To change something build a new model that makes

the existing model obsolete " - Buckminster Fuller

Pamela

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office

> practices where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to

> fill me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

> was still having sharp pain in the throat so Prevacid was increased

> to 30mg. I was on that for a while ... I was still having pain and

> flare ups then we changed to Nexium 40mg (ironically because the

> insurance would not cover the Prevacid) I don't know if this makes

> sense, but the change to Nexium, turned out to work better. The pain

> was better and the flare ups have been much less. I don't know what

> else would work...guess I'll let you figure that out. I hate the

> thought of changing something that is working! "

>

> So now I will send this off to her insurance company to see if they

> will agree. If not I may have to send her to a gastroenterologist

> who will have to document via upper endoscopy her continued need for

> the medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and

> then procedure that might not have been necessary, and all of this

> might be because the insurance company has negotiated a better

> kickback from a different pharmarmaceutical maker this year and wants

> to drive market share in their direction.

> L. Gordon MD

>

[Guest guest]

Sometimes, when physicians are looking for the enemy, all they need

to do is look in the mirror. If I have my history right, Medicare

was looked at with horror initially, until it was seen that

physicians could get paid promptly with whatever price they deemed

reasonable. This, accompanied by the rise of insurance coverage

from work was a veritable bonanza for physicians in the 1960s, 70s

and even 80s. (Even family physicians). We have created the bed

that we now sleep in- to use your analogy. (Unfortunately younger

doctors have missed the gravy train).

I certainly agree that the barriers put up by 3rd parties only serve

to increase cost and heartache.

So, I'm actually okay with various family physicians and primary

care doctors not accepting insurance, if they feel so inclined and

have the financial wherewithal to do so. My nihilistic outlook

believes that this American system will not change without pain on

the patient and physician side.

> >

> > I suspect that the net effect of prior auth is to actually

increase

> > health care costs, but by shifting much of that cost to office

> > practices where it is difficult to track.

> >

> > Here's a real life scenario from today:

> >

> > A patient of mine is in a fix. Her insurance company is

suddenly

> > requiring prior authorization for her Nexium. The insurance

company

> > wants to save money - a good goal, but will this policy have the

> > intended effect?

> > Because the insurance company is asking for information about

how she

> > started this medicine and I don't have the details, I asked her

to

> > fill me in on how she ended up with this medicine.

> > Her response via email:

> >

> > " Regarding the Nexium, I have only taken Prevacid starting at

15mg,

> > was still having sharp pain in the throat so Prevacid was

increased

> > to 30mg. I was on that for a while ... I was still having pain

and

> > flare ups then we changed to Nexium 40mg (ironically because the

> > insurance would not cover the Prevacid) I don't know if this

makes

> > sense, but the change to Nexium, turned out to work better. The

pain

> > was better and the flare ups have been much less. I don't know

what

> > else would work...guess I'll let you figure that out. I hate the

> > thought of changing something that is working! "

> >

> > So now I will send this off to her insurance company to see if

they

> > will agree. If not I may have to send her to a

gastroenterologist

> > who will have to document via upper endoscopy her continued need

for

> > the medication.

> >

> > As an attempt to help reduce health care costs, I see only

increase

> > costs to this practice for the amount of time spent by various

staff,

> > and an increase in health care expenditures for a consultation

and

> > then procedure that might not have been necessary, and all of

this

> > might be because the insurance company has negotiated a better

> > kickback from a different pharmarmaceutical maker this year and

wants

> > to drive market share in their direction.

> > L. Gordon MD

> >

>

[Guest guest]

And

just to add to the mud….at least

3 or 4 times a year I get asked to sign a death certificate for a

(relatively) young adult and to say “natural causes” when the coroner, the family and

everybody else knows it was a suicide…But if we say that, then the life

insurance policy doesn’t pay.

I didn’t even see the body, but everybody winks and says “if

you don’t help out…”

Even the newspaper plays along and does not seek an actual cause of

death. So why does a 35 year old

die “unexpectedly at home”?

And why can’t the coroner say what the cause of death might be?

I deeply question the morality of my

action, but if there are young children, I couldn’t live with myself if I thought I was

taking food out of their mouths…

Annie

Does prior authorization really save

health

care dollars?

I suspect that the net effect of prior auth is to actually increase

health care costs, but by shifting much of that cost to office practices

where it is difficult to track.

Here's a real life scenario from today:

A patient of mine is in a fix. Her insurance company is suddenly

requiring prior authorization for her Nexium. The insurance company

wants to save money - a good goal, but will this policy have the

intended effect?

Because the insurance company is asking for information about how she

started this medicine and I don't have the details, I asked her to fill

me in on how she ended up with this medicine.

Her response via email:

" Regarding the Nexium, I have only taken Prevacid starting at 15mg, was

still having sharp pain in the throat so Prevacid was increased to 30mg.

I was on that for a while ... I was still having pain and flare ups then

we changed to Nexium 40mg (ironically because the insurance would not

cover the Prevacid) I don't know if this makes sense, but the change to

Nexium, turned out to work better. The pain was better and the flare ups

have been much less. I don't know what else would work...guess I'll let

you figure that out. I hate the thought of changing something that is

working! "

So now I will send this off to her insurance company to see if they will

agree. If not I may have to send her to a gastroenterologist who will

have to document via upper endoscopy her continued need for the

medication.

As an attempt to help reduce health care costs, I see only increase

costs to this practice for the amount of time spent by various staff,

and an increase in health care expenditures for a consultation and then

procedure that might not have been necessary, and all of this might be

because the insurance company has negotiated a better kickback from a

different pharmarmaceutical maker this year and wants to drive market

share in their direction.

L. Gordon MD

[Guest guest]

Annie --

" at least 3 or 4 times a year " ... wow, you really must have a panel that

is off the tailend of the bell curve. I don't have that many deaths of

young patients in any year of any cause.

How many death certificates do you sign in total?

Tim

--

Malia, MD

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

(phone / fax)

www.relayhealth.com/doc/DrMalia

www.SkinSenseLaser.com

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> And just to add to the mud..at least 3 or 4 times a year I get asked to

> sign a death certificate for a (relatively) young adult and to say

> " natural causes " when the coroner, the family and everybody else knows

> it was a suicide.But if we say that, then the life insurance policy

> doesn't pay. I didn't even see the body, but everybody winks and says

> " if you don't help out. " Even the newspaper plays along and does not

> seek an actual cause of death. So why does a 35 year old die

> " unexpectedly at home " ? And why can't the coroner say what the cause of

> death might be?

> I deeply question the morality of my action, but if there are young

> children, I couldn't live with myself if I thought I was taking food

> out of their mouths.

> Annie

>

> Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg, was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

[Guest guest]

If the coroner was involved he/she should be completing the death certificate.

Also, " natural causes " is woefully inadequate by itself. That might be the

manner of death, but what was the cause of death?

>

>

> Date: 2007/01/22 Mon PM 08:30:44 EST

> To: < >

> Subject: RE: Does prior authorization really save

health care dollars?

>

> And just to add to the mud..at least 3 or 4 times a year I get asked to

> sign a death certificate for a (relatively) young adult and to say

> " natural causes " when the coroner, the family and everybody else knows

> it was a suicide.But if we say that, then the life insurance policy

> doesn't pay. I didn't even see the body, but everybody winks and says

> " if you don't help out. " Even the newspaper plays along and does not

> seek an actual cause of death. So why does a 35 year old die

> " unexpectedly at home " ? And why can't the coroner say what the cause of

> death might be?

> I deeply question the morality of my action, but if there are young

> children, I couldn't live with myself if I thought I was taking food

> out of their mouths.

> Annie

>

> Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg, was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

>

>

[Guest guest]

I have made it a policy only to be totally honest with death certificates or any other official forms. If I don't know the cause of death I don't sign. Patients all the time want me to fudge the truth but I tell them that I could lose my license if I am not honest and everyone backs off. Not telling the truth seems to be very slippery slope.Larry Lindeman MDAnd just to add to the mud….at least  3 or 4 times a year I get asked to sign a death certificate for a (relatively) young adult and to say “natural causes”  when the coroner, the family and everybody else knows it was a suicide…But if we say that, then the life insurance policy doesn’t pay.  I didn’t even see the body, but everybody winks and says “if you don’t help out…”  Even the newspaper plays along and does not seek an actual cause of death.  So why does a 35 year old die “unexpectedly at home”?  And why can’t the coroner say what the cause of death might be? I deeply question the morality of my action, but if there are young children, I couldn’tlive  with myself if I thought I was taking food out of their mouths…Annie  Does prior authorization really save healthcare dollars?I suspect that the net effect of prior auth is to actually increasehealth care costs, but by shifting much of that cost to office practiceswhere it is difficult to track.Here's a real life scenario from today:A patient of mine is in a fix. Her insurance company is suddenlyrequiring prior authorization for her Nexium. The insurance companywants to save money - a good goal, but will this policy have theintended effect?Because the insurance company is asking for information about how shestarted this medicine and I don't have the details, I asked her to fillme in on how she ended up with this medicine.Her response via email:"Regarding the Nexium, I have only taken Prevacid starting at 15mg, wasstill having sharp pain in the throat so Prevacid was increased to 30mg.I was on that for a while ... I was still having pain and flare ups thenwe changed to Nexium 40mg (ironically because the insurance would notcover the Prevacid) I don't know if this makes sense, but the change toNexium, turned out to work better. The pain was better and the flare upshave been much less. I don't know what else would work...guess I'll letyou figure that out. I hate the thought of changing something that isworking!"So now I will send this off to her insurance company to see if they willagree. If not I may have to send her to a gastroenterologist who willhave to document via upper endoscopy her continued need for themedication.As an attempt to help reduce health care costs, I see only increasecosts to this practice for the amount of time spent by various staff,and an increase in health care expenditures for a consultation and thenprocedure that might not have been necessary, and all of this might bebecause the insurance company has negotiated a better kickback from adifferent pharmarmaceutical maker this year and wants to drive marketshare in their direction.L. Gordon MD

[Guest guest]

I rarely know for sure…I comb the

record for SOME halfway plausible thing to say, then

pray that nobody ever asks for details. I feel as if I am sucked into a giant

conspiracy. If nobody questions my “respiratory

failure”, due to ‘chronic obstructive lung disease” due to”tobacco abuse” (and so far, nobody has) then the

young widow and her children get the death benefits…

I have never refused...and I don’t

know what would happen if I did, but like I said, if there are young kids

involved I couldn’t live with myself if it was my moral superiority that

was depriving them of their chance at college…

On one occasion I DID say out loud to the

coroner that when heard of the death, the first thing I thought of was suicide.

It was a single guy, age 32, who dutifully came in every three months. I prescribed an SSRI (which he

never filled) and 21 Lortab 7.5 per month for back

pain. I never dreamed he would save

them up, wash them down with a fifth of Kentucky bourbon and put a plastic bag over his head. But he did. The girl friend (also my patient) called

the police, they called the coroner, and he called me. Then he “suggested” that the

corpse had a bit of a yellowish tinge, and didn’t this fellow have a bit

of an alcohol problem?...

She is still my patient and is living

well, having collected a half million dollar death benefit. After I said out loud that I suspected

suicide, and she was not even legally related. If I object, she loses, the

coroner gains nothing, I gain nothing, he died for nothing, and some

corporation saves money…. What would you do….really?

Annie

Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

>

>

[Guest guest]

Annie,

Don’t do it. Could you live with

yourself when you lose your license and get fined for fraud? I have never been

asked to lie on a death certificate. I have been asked to sign it when an ME

refused to take the case saying there was nothing suspicious.

If the ME wants to say “natural

causes”, top of head spontaneous exploded, let them. Insurance companies

do investigate stuff like this, trying not to pay out.

Kathy Saradarian, MD

Branchville, NJ

Solo low-staff practice since

4/03

In practice since 9/90

Practice Partner User since 5/03

[Guest guest]

I

pulled my “special” file and it looks like I signed 11 death

certificates in 2006. Six of them

were elderly people who I knew or suspected to have a terminal condition. The other five were all most likely

suicides, although 2 were sort of questionable and might have had a legitimate

natural cause…but we’ll never know because the coroners declined to

pursue it…and I played along..

Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

[Guest guest]

Did

I mention that coroner is an elected office?

Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

[Guest guest]

Annie,Maybe I'm being too idealistic here, but if you don't *KNOW* it's a suicide, then maybe it's not. Maybe it's homocide meant to look like a suicide or an accident. It happens.I'm reminded of this news story last year of 2 elderly women who allegedly befriended homeless men, had them sign life insurance forms listing you-know-who as the beneficiaries, then shortly thereafter these homeless guys would mysteriously get killed in a hit and run car accident, making you-know-who a little richer. http://www.washingtonpost.com/wp-dyn/content/article/2006/05/22/AR2006052201359.htmlTruth is stranger than fiction sometimes. Anyways, bad stuff happens. We can't fix everything, but if I'm going to lie, you better give me a real good reason. Plus when you make an exception once, people learn to expect you to do it again. What would happen if you said, "Sorry, I can't sign the death certificate because I don't know why Mr. died." They might go try and ask someone else, but they probably won't ask you again. I know, easier said than done. SetoSouth Pasadena, CAAnd just to add to the mud….at least  3 or 4 times a year I get asked to sign a death certificate for a (relatively) young adult and to say “natural causes”  when the coroner, the family and everybody else knows it was a suicide…But if we say that, then the life insurance policy doesn’t pay.  I didn’t even see the body, but everybody winks and says “if you don’t help out…”  Even the newspaper plays along and does not seek an actual cause of death.  So why does a 35 year old die “unexpectedly at home”?  And why can’t the coroner say what the cause of death might be? I deeply question the morality of my action, but if there are young children, I couldn’tlive  with myself if I thought I was taking food out of their mouths…Annie

[Guest guest]

Here's a quotation from the Sunday NY TImes on just this subject:"Caremark RX is a large pharmaceuticals benefits manager. Generally, this means that it makes money by denying benefits of various kinds, especially prescriptions, to patients and employees, thus supposedly saving money for employers and keeping a big chunk of that money for itself."I think these companies probably have actuaries who figure out how often PAs are applied for or how often GIs are consulted vs how many people just lose their medicine, but maybe that's cynical.  I suspect that the net effect of prior auth is to actually increase health care costs, but by shifting much of that cost to office practices where it is difficult to track.Here's a real life scenario from today:A patient of mine is in a fix.  Her insurance company is suddenly requiring prior authorization for her Nexium.  The insurance company wants to save money - a good goal, but will this policy have the intended effect?Because the insurance company is asking for information about how she started this medicine and I don't have the details, I asked her to fill me in on how she ended up with this medicine.Her response via email:"Regarding the Nexium, I have only taken Prevacid starting at 15mg, was still having sharp pain in the throat so Prevacid was increased to 30mg. I was on that for a while ... I was still having pain and flare ups then we changed to Nexium 40mg (ironically because the insurance would not cover the Prevacid) I don't know if this makes sense, but the change to Nexium, turned out to work better. The pain was better and the flare ups have been much less. I don't know what else would work...guess I'll let you figure that out. I hate the thought of changing something that is working!"So now I will send this off to her insurance company to see if they will agree.  If not I may have to send her to a gastroenterologist who will have to document via upper endoscopy her continued need for the medication.As an attempt to help reduce health care costs, I see only increase costs to this practice for the amount of time spent by various staff, and an increase in health care expenditures for a consultation and then procedure that might not have been necessary, and all of this might be because the insurance company has negotiated a better kickback from a different pharmarmaceutical maker this year and wants to drive market share in their direction.L. Gordon MD

[Guest guest]

-I had a patient last week at 4:30 that I thought had an appy, but it was too late for me to get a CT for them through the "daytime" CT shops, so I had to send them to the ER. I called the ER doc, let them know this one was probably real, it took her 7 hours to get in a room, diagnosis made 11 hours after I saw her, surgery 18 hours after I saw her. A friend told me the story of a young American woman in way rural Brazil, who developed abdominal pain, diagnosed herself with a book, had to be driven 6 hours to the hospital and was operated on immediately. Her family is horrified that it was so far to the hospital!. Meanwhile, I'm thinking I should start transporting to the hospital in Brazil. Gordon,I couldn’t agree more. Example: In this area, many of the PPOs now require prior auth for all CT scans. The other day, I had a patient come in with nonspecific abdominal pain but he is someone who NEVER complains about anything. I was worried enough that I wanted to get a CT. Of course it was a Wednesday (my nurse is off), so I had to spend 30 minutes with the insurance company getting the proper paperwork done. He had the CT which showed a ruptured appendix. So what would have happened if I didn’t have the 30 minutes? Would I have just decided to do watchful waiting? Would the patient have died of peritonitis?I firmly believe putting up barriers to care ends up costing way more money than it would ever save. Even worse, the insurance company never assumes responsibility for the bad outcomes incurred by the barriers. This remains one of the most challenging problems I see in our current medical system.  Does prior authorization really save health care dollars? I suspect that the net effect of prior auth is to actually increase health care costs, but by shifting much of that cost to office practices where it is difficult to track.Here's a real life scenario from today:A patient of mine is in a fix.  Her insurance company is suddenly requiring prior authorization for her Nexium.  The insurance company wants to save money - a good goal, but will this policy have the intended effect?Because the insurance company is asking for information about how she started this medicine and I don't have the details, I asked her to fill me in on how she ended up with this medicine.Her response via email:"Regarding the Nexium, I have only taken Prevacid starting at 15mg, was still having sharp pain in the throat so Prevacid was increased to 30mg. I was on that for a while ... I was still having pain and flare ups then we changed to Nexium 40mg (ironically because the insurance would not cover the Prevacid) I don't know if this makes sense, but the change to Nexium, turned out to work better. The pain was better and the flare ups have been much less. I don't know what else would work...guess I'll let you figure that out. I hate the thought of changing something that is working!"So now I will send this off to her insurance company to see if they will agree.  If not I may have to send her to a gastroenterologist who will have to document via upper endoscopy her continued need for the medication.As an attempt to help reduce health care costs, I see only increase costs to this practice for the amount of time spent by various staff, and an increase in health care expenditures for a consultation and then procedure that might not have been necessary, and all of this might be because the insurance company has negotiated a better kickback from a different pharmarmaceutical maker this year and wants to drive market share in their direction.L. Gordon MD

[Guest guest]

I’m

not really sure if your death certificates are the same as mine then, because

mine have a “manner of death” (ie, suicide, natural causes, etc)

and a “cause of death” (ie, acute GI hemorrhage). I am

actually deputy coroner for my rural county, and I can not just state “natural

causes” and leave it at that. Is a hanging, etc really “natural

causes? Is asphyxiation (secondary to hanging) really natural causes?

No. If there was a suspected suicide then it needs to be a coroners

case. iF they refuse then thee county office needs to be made aware, as

he/she is an elected official.

RE:

Does prior authorization really save health care

dollars?

Annie,

Don’t do it.

Could you live with yourself when you lose your license and get fined for

fraud? I have never been asked to lie on a death certificate. I

have been asked to sign it when an ME refused to take the case saying there was

nothing suspicious.

If the ME wants to say

“natural causes”, top of head spontaneous exploded, let them.

Insurance companies do investigate stuff like this, trying not to pay

out.

Kathy

Saradarian, MD

Branchville,

NJ

Solo low-staff practice

since 4/03

In practice

since 9/90

Practice

Partner User since 5/03

[Guest guest]

To me there is no question that " prior auth " costs more in terms of money and

in some cases, life.

My anecdotal experience was with Anthem recently when they decided, after the

fact, that a CT of my patient's abdomen was going to be denied.

She is in her late 40's and one of my " non-complainers " . She came in

complaining of abdominal bloating, non-specific pain in her lower abdomen and

some mild weight loss. Physical exam, including breast and pelvic exams, was

normal. She had her gallbladder removed in the past. Very remote family

history of uterine cancer and breast cancer. I debated getting an US, but

decided that I would end up getting an abdominal CT if the US was normal, so I

elected to go ahead and get the CT and save the expense of the US.

The CT revealed an " supicious lesion consistent with early ovarian cancer. "

After I received the results and had gotten her set up with surgeons/oncology

etc, I received notification that they were not going to pay for the CT scan.

I immediately got on the phone and after multiple transfers, got to talk to a

" medical director MD " who told me I should have done an US first and a CA-125.

If I had gotten these, he would have considered " allowing " the CT scan.

To make a long story short, I ended up literally shaming him into authorizing

payment for her positive CT scan.

I am still outraged that it would take this kind of effort to get insurance

agencies to provide the payment for services they are contracted to provide.

I am saddened to see the insurance industry returning to the old habits of

putting up roadblocks to patient care.

, M.D.

Durango, CO

On Mon, 22 Jan 2007 18:21:44 -0000

" roxywible " wrote:

> Gordon,

>

> Agree completely.

>

> How did all these folks squeeze their way into the sacred

> patient/physician relationship?

>

> Layers upon layers of regulation and " self-fulfilling

> bureacracy " $$$$$ and then we work harder to pay for all

> these people to micromanage us to death and to

> the ultimate detriment of our patients.

>

> If we suddenly woke up in the middle of the night and

> discovered our CPA and insurance agent, plumber,

> electrician, and techie guy in bed between ourselves and

> our spouse we would wonder...

>

> " how did these people insert themselves into this sacred union? "

>

> and then we'd call the police.

>

> We need to take back our profession.

>

> Thanks for all you do Gordon. I quote you frequently!

> Keep compiling the data....

>

>

> " You never change things by fighting the existing reality.

> To change something build a new model that makes

> the existing model obsolete " - Buckminster Fuller

>

>

> Pamela

>

>

>

>>

>> I suspect that the net effect of prior auth is to actually increase

>> health care costs, but by shifting much of that cost to office

>> practices where it is difficult to track.

>>

>> Here's a real life scenario from today:

>>

>> A patient of mine is in a fix. Her insurance company is suddenly

>> requiring prior authorization for her Nexium. The insurance company

>> wants to save money - a good goal, but will this policy have the

>> intended effect?

>> Because the insurance company is asking for information about how she

>> started this medicine and I don't have the details, I asked her to

>> fill me in on how she ended up with this medicine.

>> Her response via email:

>>

>> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

>> was still having sharp pain in the throat so Prevacid was increased

>> to 30mg. I was on that for a while ... I was still having pain and

>> flare ups then we changed to Nexium 40mg (ironically because the

>> insurance would not cover the Prevacid) I don't know if this makes

>> sense, but the change to Nexium, turned out to work better. The pain

>> was better and the flare ups have been much less. I don't know what

>> else would work...guess I'll let you figure that out. I hate the

>> thought of changing something that is working! "

>>

>> So now I will send this off to her insurance company to see if they

>> will agree. If not I may have to send her to a gastroenterologist

>> who will have to document via upper endoscopy her continued need for

>> the medication.

>>

>> As an attempt to help reduce health care costs, I see only increase

>> costs to this practice for the amount of time spent by various staff,

>> and an increase in health care expenditures for a consultation and

>> then procedure that might not have been necessary, and all of this

>> might be because the insurance company has negotiated a better

>> kickback from a different pharmarmaceutical maker this year and wants

>> to drive market share in their direction.

>> L. Gordon MD

>>

>

>

[Guest guest]

MAY BE THERE ARE OTHER WAYS TO TREAT THESE PATIENTS? TRY DIGESTIVE ENZYMES

WITH MEALS AND / SOME HCL AND SOME PROBIOTICS

> Did I mention that coroner is an elected office?

>

> Does prior authorization really save

>> health

>> care dollars?

>>

>> I suspect that the net effect of prior auth is to actually increase

>> health care costs, but by shifting much of that cost to office

> practices

>> where it is difficult to track.

>>

>> Here's a real life scenario from today:

>>

>> A patient of mine is in a fix. Her insurance company is suddenly

>> requiring prior authorization for her Nexium. The insurance company

>> wants to save money - a good goal, but will this policy have the

>> intended effect?

>> Because the insurance company is asking for information about how she

>> started this medicine and I don't have the details, I asked her to

> fill

>> me in on how she ended up with this medicine.

>> Her response via email:

>>

>> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

> was

>> still having sharp pain in the throat so Prevacid was increased to

> 30mg.

>> I was on that for a while ... I was still having pain and flare ups

> then

>> we changed to Nexium 40mg (ironically because the insurance would not

>> cover the Prevacid) I don't know if this makes sense, but the change

> to

>> Nexium, turned out to work better. The pain was better and the flare

> ups

>> have been much less. I don't know what else would work...guess I'll

> let

>> you figure that out. I hate the thought of changing something that is

>> working! "

>>

>> So now I will send this off to her insurance company to see if they

> will

>> agree. If not I may have to send her to a gastroenterologist who will

>> have to document via upper endoscopy her continued need for the

>> medication.

>>

>> As an attempt to help reduce health care costs, I see only increase

>> costs to this practice for the amount of time spent by various staff,

>> and an increase in health care expenditures for a consultation and

> then

>> procedure that might not have been necessary, and all of this might be

>> because the insurance company has negotiated a better kickback from a

>> different pharmarmaceutical maker this year and wants to drive market

>> share in their direction.

>> L. Gordon MD

>>

>

[Guest guest]

From the Old MD in Drain, Oregon, As I have said before, the health care system is a system under seige, with all the problems that come from that attitude. Gordon, Here you have an example of some company wanting to shift the problem to someone else (you) and the savings comes to the insurance company when they have such policies because the average MD will not go through the trouble you are going through to help the patient. Voila! Cost savings because the patient goes away and pays for the medicine him or herself a good portion of the time. This is just a fancy way to make a bid for further "patient responsibility" for the costs of medicine. Our current health care system is as full of doublespeak as a science fiction novel. Please note: there is a single payer system in Slovokia. Joanne Holland DVM/MD Annie Skaggs wrote: And just to add to the mud….at least 3 or 4 times a year I get asked to sign a death certificate for a (relatively) young adult and to say “natural

causes” when the coroner, the family and everybody else knows it was a suicide…But if we say that, then the life insurance policy doesn’t pay. I didn’t even see the body, but everybody winks and says “if you don’t help out…” Even the newspaper plays along and does not seek an actual cause of death. So why does a 35 year old die “unexpectedly at home”? And why can’t the coroner say what the cause of death might be? I deeply question the morality of my action, but if there are young children, I couldn’t live with myself if I thought I was taking food out of their mouths… Annie Does prior

authorization really save healthcare dollars?I suspect that the net effect of prior auth is to actually increasehealth care costs, but by shifting much of that cost to office practiceswhere it is difficult to track.Here's a real life scenario from today:A patient of mine is in a fix. Her insurance company is suddenlyrequiring prior authorization for her Nexium. The insurance companywants to save money - a good goal, but will this policy have theintended effect?Because the insurance company is asking for information about how shestarted this medicine and I don't have the details, I asked her to fillme in on how she ended up with this medicine.Her response via email:"Regarding the Nexium, I have only taken Prevacid starting at 15mg, wasstill having sharp pain in the throat so Prevacid was increased to 30mg.I was on that for a while ... I was still having pain and flare ups thenwe changed to

Nexium 40mg (ironically because the insurance would notcover the Prevacid) I don't know if this makes sense, but the change toNexium, turned out to work better. The pain was better and the flare upshave been much less. I don't know what else would work...guess I'll letyou figure that out. I hate the thought of changing something that isworking!"So now I will send this off to her insurance company to see if they willagree. If not I may have to send her to a gastroenterologist who willhave to document via upper endoscopy her continued need for themedication.As an attempt to help reduce health care costs, I see only increasecosts to this practice for the amount of time spent by various staff,and an increase in health care expenditures for a consultation and thenprocedure that might not have been necessary, and all of this might bebecause the insurance company has negotiated a better kickback from adifferent

pharmarmaceutical maker this year and wants to drive marketshare in their direction.L. Gordon MD

Have a burning question? Go to Yahoo! Answers and get answers from real people who know.

[Guest guest]

You can use this insurance stuff for those of you that need more

volume to generate and office visit, discuss the alternatives,

generics etc and frequently save the patient a small fortune. Turn

them into practice opportunities to help your patient and not

uncompensated care. If you can save them 10 dollars a month you have

more than saved your office call.

Brent

> And just to add to the mud….at least 3 or 4 times a

year I get asked to sign a death certificate for a (relatively) young

adult and to say " natural causes " when the coroner, the family and

everybody else knows it was a suicide…But if we say that, then the

life insurance policy doesn't pay. I didn't even see the body, but

everybody winks and says " if you don't help out… " Even the newspaper

plays along and does not seek an actual cause of death. So why does

a 35 year old die " unexpectedly at home " ? And why can't the coroner

say what the cause of death might be?

> I deeply question the morality of my action, but if there are

young children, I couldn't live with myself if I thought I was

taking food out of their mouths…

> Annie

>

> Does prior authorization really

save health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office

practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how

she

> started this medicine and I don't have the details, I asked her to

fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

was

> still having sharp pain in the throat so Prevacid was increased to

30mg.

> I was on that for a while ... I was still having pain and flare ups

then

> we changed to Nexium 40mg (ironically because the insurance would

not

> cover the Prevacid) I don't know if this makes sense, but the

change to

> Nexium, turned out to work better. The pain was better and the

flare ups

> have been much less. I don't know what else would work...guess I'll

let

> you figure that out. I hate the thought of changing something that

is

> working! "

>

> So now I will send this off to her insurance company to see if they

will

> agree. If not I may have to send her to a gastroenterologist who

will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various

staff,

> and an increase in health care expenditures for a consultation and

then

> procedure that might not have been necessary, and all of this might

be

> because the insurance company has negotiated a better kickback from

a

> different pharmarmaceutical maker this year and wants to drive

market

> share in their direction.

> L. Gordon MD

>

>

>

>

>

>

>

>

>

>

> ---------------------------------

> Have a burning question? Go to Yahoo! Answers and get answers from

real people who know.

>

[Guest guest]

So

what was the CAUSE of death (not the manner of death)? That is the

key. It is kind of hard to say “natural causes” & then

list asphyxiation as the cause. Alcoholism is not a cause either, at

least not primary. Just curious. Sounds like the coroner needs to

be accepting more cases than they do. Basicall, all of those cases are

handled by the coroner here.

Does prior authorization really save

> health

> care dollars?

>

> I suspect that the net effect of prior auth is to actually increase

> health care costs, but by shifting much of that cost to office practices

> where it is difficult to track.

>

> Here's a real life scenario from today:

>

> A patient of mine is in a fix. Her insurance company is suddenly

> requiring prior authorization for her Nexium. The insurance company

> wants to save money - a good goal, but will this policy have the

> intended effect?

> Because the insurance company is asking for information about how she

> started this medicine and I don't have the details, I asked her to fill

> me in on how she ended up with this medicine.

> Her response via email:

>

> " Regarding the Nexium, I have only taken Prevacid starting at 15mg,

was

> still having sharp pain in the throat so Prevacid was increased to 30mg.

> I was on that for a while ... I was still having pain and flare ups then

> we changed to Nexium 40mg (ironically because the insurance would not

> cover the Prevacid) I don't know if this makes sense, but the change to

> Nexium, turned out to work better. The pain was better and the flare ups

> have been much less. I don't know what else would work...guess I'll let

> you figure that out. I hate the thought of changing something that is

> working! "

>

> So now I will send this off to her insurance company to see if they will

> agree. If not I may have to send her to a gastroenterologist who will

> have to document via upper endoscopy her continued need for the

> medication.

>

> As an attempt to help reduce health care costs, I see only increase

> costs to this practice for the amount of time spent by various staff,

> and an increase in health care expenditures for a consultation and then

> procedure that might not have been necessary, and all of this might be

> because the insurance company has negotiated a better kickback from a

> different pharmarmaceutical maker this year and wants to drive market

> share in their direction.

> L. Gordon MD

>

>

>

[Guest guest]

I have a similar story about ruptured appy, and a horrendous day in the office this Tuesday. Too much to go into. My question, sorry if prev posted, are we doing the Thurs phone calls? I was out of town for a planned surgery for my mother and came back to hunreds of posts. If there is one tonight, could someone drop me a quick line for the number?.

Cote

Four Corners Family Medicine

--------- Does prior authorization really save health care dollars?

I suspect that the net effect of prior auth is to actually increase health care costs, but by shifting much of that cost to office practices where it is difficult to track.Here's a real life scenario from today:A patient of mine is in a fix. Her insurance company is suddenly requiring prior authorization f

or her Nexium. The insurance company wants to save money - a good goal, but will this policy have the intended effect?Because the insurance company is asking for information about how she started this medicine and I don't have the details, I asked her to fill me in on how she ended up with this medicine.Her response via email:"Regarding the Nexium, I have only taken Prevacid starting at 15mg, was still having sharp pain in the throat so Prevacid was increased to 30mg. I was on that for a while .

... I was still having pain and flare ups then we changed to Nexium 40mg (ironically because the insurance would not cover the Prevacid) I don't know if this makes sense, but the change to Nexium, turned out to work better. The pain was better and the flare ups have been much less. I don't know what else would work...guess I'll let you figure that out. I hate the thought of changing something that is working!"So now I will send this off to her insurance company to see if they will agree. If not I may have to send her to a gastroenterologist who will have to document via upper endoscopy her continued need for the medication.As an attempt to help reduce health care costs, I see only increase costs to this practice for the amount of time spent by various staff, and an increase in health care expenditures for a consultation and then procedure that might not have been necessary, and all of this might be because the insurance company has negotiated a better kickback from a different pharmarmaceutical maker this year and wants to drive market share in their direction.L. Gordon MD