New York physician - letter criticizes insurance company patient interference

Health insurance company utilization management programs (e.g. prior authorization and step therapy), can create significant barriers for patients by delaying the start or continuation of necessary treatment, possibly negatively affecting their outcomes. ~ Dr. Peter Ronchetti 

Letter to the editor published in the:

Patient-centered care has emerged as a common goal across the health care industry. By empowering patients to play an active role with their physician in developing individualized treatment plans, this care model can increase patients’ satisfaction and improve treatment quality and outcomes, while reducing or eliminating unnecessary costs.

Despite these clear advantages to adopting patient-centered care, physicians and patients often face significant obstacles in putting this concept into practice.

Health insurance company utilization management programs (e.g. prior authorization and step therapy), can create significant barriers for patients by delaying the start or continuation of necessary treatment, possibly negatively affecting their outcomes. The highly manual, time-consuming processes used in these programs burden physicians, pharmacies and hospitals and divert valuable resources away from direct patient care.

The question is, “who knows best?” Is it a non-physician practitioner at the end of a phone line asking multiple questions? 

Is it an insurance company whose share price goes up as they make more profit from your premiums? The answer is simple: Physicians know best. We were trained to look out for our patients’ best interests. If a patient has disabling arthritis, a mechanical problem with loss of cartilage, who is best equipped to determine the most appropriate treatment? If a physician believes that cortisone injections or physical therapy will improve a patient’s condition to the point they don’t need surgery, then they will order it. The patient does not benefit from the insurance company telling us to put you through painful therapy and/or injections if it will not change the course of the disease.

The concept of prior authorizations should be discussed with the parties involved and not dictated by how much money the insurance company allocates for a given condition, or their idea that a procedure is over utilized.

In fact, this only delays care and costs both the patient and the insurance company more money in the long run.

Patients come to physicians for guidance and trust us to look out for their best interests so why is it that insurance companies do not believe we are doing this? Unfortunately, these bureaucratic bottlenecks do not serve patients and cause wasteful spending in our healthcare system.

Physician leaders in this community should be consulted before broad prior authorization programs are implemented. Monroe County Medical Society welcomes payers to share their concerns with our Quality Collaborative, which is comprised of key community healthcare stakeholders.

What you don’t need are more barriers to accessing the treatment your trusted physician recommends. When you see your doctor next, ask him or her if the treatment you are getting is based on clinical judgment or your insurance company’s protocol. 

If it’s the latter, call your insurance company and let them know “Who knows best”.

Dr. Peter Ronchetti is president of the Monroe County Medical Society.