Most physicians (depending on specialty) spend between 3-8 years training after graduating from medical school. During this time, we gain valuable experience in evaluating and treating patients with real problems during our internships, residencies and fellowships. When learn judgement–when and where to test and when to perform invasive procedures. On the job experience cannot be replaced. As housestaff, physicians are witness to all phases of the disease process–the beginning, the middle and the end.
Medicine has changed. In the past, a physician’s life was dominated by the quest to provide excellent patient care. Now, medicine is driven by insurance payers, hospital, and government regulations. Physicians are now required to ask permission to schedule tests and procedures. No longer is our “experience” and instinct enough. No longer can we interact with our patient, perform a thorough history and physical exam and then order an indicated test or procedure. Often we are required to have “peer to peer” case discussions with physicians who are employed by the insurance companies in order to obtain approval to proceed. Most of the time, these physicians are not trained in any specific specialty and have never performed the procedure they are tasked with approving. Surprisingly, many of these “approval” physicians have no current experience with clinical medicine.
Today an article in the Wall Street Journal reported on a new study from the Annals of Emergency Medicine published this week that examined the amount of time physicians spend on seeking approvals for psychiatric admissions. In the study, researchers tabulated the amount of time that physicians spent on the phone obtaining approval for psychiatric admissions as well as the length of time patients spent awaiting approvals in the emergency department. The study was conducted over a 3 month time period and found that, on average, physicians spent nearly 38 minutes on the phone seeking approvals. In 10% of cases the time on the phone exceeded one hour. Most of the requests (all but one ) evaluated in the study were ultimately approved but resulted in lots of wasted hours for physicians. In fact, the total time wasted in the study was tallied at more than 1 million hours. While tied up on the phone seeking approvals, physicians were pulled away from other more important patient care tasks and productivity suffered. Moreover, ED bed space was occupied for great lengths of time during the approval time–the mean stay was 8 hours and the longest was 20 hours. ED bed space can be at a premium in a major metropolitan area and the approval process may have resulted in delay in care to other patients.
Certainly, approval delays and physician time waste is not limited to psychiatric admissions. In order to keep up with the demands of pre approvals from insurers, we have had to create entire departments in our practice with employees devoted to interacting with approval agents from insurance companies. In my specialty, I often have to seek approval for Implantable Cardioverter Defibrillator (ICD) implantations as well as stress testing. Many times I have to explain to the “approving physician” exactly what an ICD is and what it is being used for. Often, the “approving physician” seems to be reading from a script provided to them by their employers–and this gives me the impression that they are charged with finding ways to say “no” in order to protect the bottom line of the company for which they work.
This particular study serves as an excellent example of the inefficiencies that occur in the system when insurance companies and regulators are allowed to drive care. Ultimately care becomes even more fractured and patient care suffers. If insurers must require approval, I suggest that they find well qualified specialists to review cases rather than physicians who are untrained in a particular specialty. In addition, streamlining the approval process and requiring less physician time on the phone will be a major step in the right direction. As physicians, we have trained many years to provide care for our patients. We must be allowed to deliver appropriate care in a timely fashion without hours on the telephone discussing cases with insurers.