'It should concern anyone who could be a patient': Where prior authorization is headed, per 1 surgeon

Payers are constantly changing prior authorization rules, keeping physicians and physician staff on their toes over what procedures may or may not be approved. 

Brian Gantwerker, MD, a neurosurgeon at the Craniospinal Center of Los Angeles, told Becker's he is concerned about the increase in prior authorizations and the decrease of physician reimbursement rates. He believes all patients should be concerned, too. 

Dr. Brian Gantwerker: In the current healthcare climate, prior authorizations have become vexingly common, even for routine tests and clearly indicated or even urgent surgeries. Recently, I had a patient with cancer who required an interventional spine procedure, and the payer declined and delayed to even engage in getting an authorization. The patient was brand new to their plan and the payer was dragging their feet. My staff spent, without embellishment, six hours on the phone being transferred from station to station, oftentimes to the same operator in the same department multiple times. The trend toward increasing bureaucratic maze walking and decreasing reimbursements and remuneration from the largest payers, including Medicare, and the shunting of more patients into what are HMOs, should concern all physicians. Since the rise of managed care in the 1980s and now incredibly byzantine private insurance systems seems to be pressuring doctors to leave medicine prematurely, close their practices and become employed, and to in some cases leave for other countries. Both Congress and the Department of Health and Human Services should be concerned for patient access to qualified physicians. Lowered fees are being justified by the bureaucracy because they state doctors' fees are driving up costs. Paradoxically, physicians reimbursement has been going down for the last 20 years, and in the case of neurosurgery by almost 25 percent.  

It begs the question, of course, how is it that if the largest driver of healthcare cost is physician fees, which have been decreasing, and certainly not being corrected nor compensated for inflation — how is it that costs keep going up? The truth is, physician fees have, for many years, only made up about 6 percent of the healthcare spend. Insurers, buoyed by both stipends from the government and shunting patients into Medicare Advantage plans that increase the number of steps and red tape doctors have to traverse to get their patients their care, have posted tens of billions in dollars in profit. We know that the other 94 percent of healthcare spend is to account for the rise in costs, with the insurers laughing all the way to the bank. With their rationing of healthcare and the policy wonks misleading Congress by stating healthcare costs of physicians are the fees charged, not the actual remuneration paid, we need to fight for our patients and ourselves.

And it should concern anyone in this healthcare system who is, or could potentially be, a patient.

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