So-called “evidence-based guidelines” are slowly destroying the practice of medicine, and companies that develop these proprietary guidelines are guilty of conspiring with payers to deny individuals necessary medical treatment.
Guideline developers, health plans, and their benefit managers contend that utilization management (UM) programs based on medically proven guidelines will reduce unwarranted clinical practice variation and improve care quality and cost. But real-world evidence paints an entirely different picture. A recent study conducted by the American Medical Association (AMA) found that:
- 88% of physicians considered prior authorization a high or extremely high burden, devoting almost 2 business days (13 hours) per week to this activity, along with staff
- 93% of physicians reported treatment delays due to prior authorization requirements, with 82% reporting treatment abandonment on some occasions, which means patients had to settle for no treatment or treatment other than what their physicians ordered
- Approximately one-third of physicians reported their patients suffered a serious adverse event due to prior authorization – hospitalization, disability or a life-threatening event
- 30% of physicians felt that utilization review criteria are rarely or never evidence-based, despite virtually all health plans asserting otherwise, and only 1% of physicians felt that prior authorization programs led to positive patient outcomes
- More than half (51%) of physicians reported that prior authorization can impact a patient’s work performance, leaving the AMA to conclude: “[I]f PA-related care delays and treatment abandonment lead to negative clinical outcomes, patients may miss work or not be as productive – hurting employers’ bottom line in the long run.”
The AMA findings contrast sharply with claims made by payers and guideline developers. Improved quality and decreased costs are simply fallacies, a BIG lie perpetrated by guideline purists for years. The truth is health care costs and inflation continue to outpace consumer costs and inflation, and the United States health system ranks last overall among 11 high-income countries in terms of access to care, care process, administrative efficiency, equity, and health care outcomes.
The names of the conspirators are quite familiar to practicing physicians. Guideline developers include Milliman and InterQual. The top five payers are United, Anthem, Aetna, Cigna, and Humana. There are also a host of companies contracted by payers – co-conspirators – that conduct specialty reviews in diverse areas ranging from behavioral health to orthopedic and spinal surgery to oncology treatment – not to mention pharmacy benefit managers who have contributed to the crisis in drug pricing and affordability.
It’s difficult to turn a blind eye to the disastrous effect of utilization management (UM) on patients and employers. The AMA has proposed a series of reforms to streamline, standardize and simplify UM procedures, particularly for medically vulnerable elderly patients. But the AMA’s suggestions haven’t fixed anything yet, and doctors’ frustrations are mounting – even the president of the AMA has shared his personal angst in writing.
The Centers for Medicare and Medicaid Services (CMS) has declined to adopt a proprietary decision support tool like Milliman or InterQual, embracing instead a broader definition of medical necessity grounded in accepted standards of medicine. In my opinion, this is the direction we need to take, eschewing utilization management altogether and returning the practice of medicine to doctors, where it belongs.
Do we really need companies like Milliman and InterQual to dictate how medicine should be practiced? Didn’t we learn that in medical school and residency training? Don’t we stay updated through continuing medical education courses and maintenance of board certification?
We certainly don’t need health insurers and their hired guns pretending to know our patients better than us. They don’t walk in our shoes. And we definitely don’t need to equip lawyers with “evidence” to be used against us in malpractice cases, which is one of the unintended consequences of evidence-based guidelines, as is the retrospective down coding and denial of claims.
Doctors prefer to think independently and exercise their own judgment in caring for patients. We prefer the evidence to inform our diagnoses and treatment. Objective findings constitute only one of many factors that underlie the art of medical practice. Surely, practical reasoning and wisdom based partly on science but mainly on experience and judgment count as much, if not more, than cost-conscious treatment algorithms.
I can’t tell you how many times I’ve heard doctors say they don’t want utilization management companies meddling in their affairs. They dislike it when physician advisers – with passion, misdirected though it might be – second-guess their clinical decisions. Of course, there are outlier physicians whose practice does not conform to medical standards, and they need to be educated and, in rare instances, disciplined. But achieving cost-effective care doesn’t require an army of pseudoscientists infringing on our turf pretending to be clinical experts. It is time for the truth to ring out loud and clear – doctors are quite capable of thinking for themselves.
Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.
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