Vice President Kamala Harris campaigned against the idea of patients having to get private insurance company approval prior to receiving medical care. She was worried about the paperwork and the delay it might cause for patients. Now, the Biden administration is seeking to expand Medicare eligibility to those age 60 and above, down from the current cutoff of 65.
The challenge is that Centers for Medicare and Medicaid Services (CMS) will be reducing actual efficient access to surgical care. Prior authorization is coming to standard government Medicare insurance on July 1.
CMS recently announced its intention to begin prior authorization for specific procedures, including spine surgery. This would require surgeons to get permission from Medicare for reimbursement before performing certain procedures.
This is a dangerous pill to swallow.
In theory, prior authorization exists to help reduce unnecessary procedures. In actuality, the practice is largely not driven by scientific data, delays care, and serves as an obstacle to prudent patient care with a cumbersome bureaucratic disruption to the patient–physician relationship.
The Biden administration simply cannot champion access while not actually ensuring access to care.
Recent data from the American Medical Association (AMA) notes that 30 percent of providers reported that prior authorization affected care delivery resulting in a serious adverse event, with 18 percent of physicians reporting the event as life-threatening.
Prior authorization is bad medicine.
The prior-authorization process does not serve as a national guidelines-based quality control process to ensure local physicians adhere to stringent medical standards. Rather, it serves as opaque obfuscation and deterrence. Review generally requires a peer-to-peer conversation after, for example, a neurosurgeon and the patient have already mutually decided on a surgical plan. The neurosurgeon or neurosurgeon’s team will then argue the merit of the case with someone lobbying on behalf of the insurance company (and, starting July 1, Medicare).
The slight caveat is that these conversations are rarely high level peer-to-peer discussions among colleagues looking to achieve best outcomes. Indeed, only 32 percent of physicians surveyed by the AMA noted the prior authorization process to be evidence-based. I have personally talked to radiologists, anesthesiologists, and even a retired pediatrician regarding the clinical need and indications for complex spine procedures.
This is fiscally driven construct.
Our peer-reviewed study published in a leading neurosurgery journal proved that private insurance companies specifically targeted higher-cost procedures. These may look like good numbers to some in a government cubicle, but these are real people with real problems who are in true agony, and many of them can’t afford to miss extra days of work or school waiting for approval.
Our spine institute at the University of South Alabama serves as an academic complex referral center at a Level 1 Trauma Center for our region. We focus on complex and vulnerable pediatric and adult patients for things like spinal deformity, scoliosis, and spine trauma. This takes interdisciplinary coordination. It takes a lot of time and effort out of the operating room. At a purely practical level, our staff will be flooded by this regulation regarding the new prior authorization requirement for cervical (neck) surgery.
My staff, especially my nurse, spends a large amount of time staying on hold, tracking down papers, faxing forms, and lobbying on behalf of our private insurance patients for everything from physical therapy to MRIs to medication. The same AMA survey noted that on average physicians and their staff spend 16 hours a week completing prior authorization requirements alone. Please don’t add our Medicare patients to the list.
The Biden administration simply cannot champion access while not actually ensuring access to care.
It should at least cause some discussion when a coalition of 40 state and national health organizations cite concern with this new regulation. Our pain management colleagues are even worried about a necessary increase in opioid prescriptions should specific neurostimulation procedures be targeted.
The challenge, of course, is that Medicare’s trustees noted that Medicare Part A, which covers hospital reimbursement, will become insolvent in 2026. Medicare is looking at private insurance companies that already perform the practice of prior authorization for cost-saving ideas.
At least with private insurance there is an imperfect marketplace of patient consumers. Too much prior authorization frustrates the patient, who can exercise a limited form of market power.
But a government monopoly on the control of the prior authorization of care cedes that reform agent into a vast milieu of governmental power. This level of disruption to the patient–physician relationship should cause even the most progressive of reformers some pause.
Richard Menger, MD, MPA, is an assistant professor of neurosurgery and an assistant professor of political science at the University of South Alabama. He is the lead editor of the textbook The Business, Policy, and Economics of Neurosurgery.
