Insurers Delay, Restrict Needed Care for Area Patients, Survey Finds
Obtaining Pre-Certification of Coverage for Medications, Tests, Procedures Can Require Multiple Steps, Take Extra Physician Time; Physicians Say They Spend More Time “Fighting Insurance Companies Than They Spend Fighting Disease”
St. Louis-area patients are experiencing delays and restrictions in receiving needed care due to insurance company practices in pre-certifying coverage, according to a new survey of the area’s physicians by the St. Louis Metropolitan Medical Society.
Physicians surveyed gave insurers a composite score of 3.19 on a scale of 1 to 5 for the promptness and ease of the pre-certification process. In pre-certification, the insurer provides the patient and physician with coverage approval for services such as tests, procedures, devices, medications, surgery and rehabilitation before they are undertaken.
Respondents were given statements to associate with a number on the scale rating ease of pre-certification for various services by various insurers. Responses range from 1 equaling “rarely to never approves prescribed medication or device” to 5 equaling “promptly approves.” In the middle, the score of 3 represents “may approve after delay and physician involvement.”
“The overall composite score of 3.19 translates to the letter grade of ‘C,’” said Samer Cabbabe, MD, FACS, president of the St. Louis Metropolitan Medical Society. “We are very concerned that these delays and restrictions impact our patients’ ability to access needed care in a timely manner.”
Dr. Cabbabe continued, “Physicians are telling us that the pre-certification process makes it more difficult to practice medicine. Patient conditions can worsen while waiting for insurance approvals, which can sometimes take as long as two weeks.”
Nearly all the physicians surveyed, 92 percent, somewhat agree or strongly agree with the statement, “My ability to practice medicine appropriately is influenced by insurance company policies on pre-certification.” In addition, 93 percent somewhat agree or strongly agree that they have had to alter a patient’s treatment plan because of restrictions from an insurance provider.
“Physicians and their staff spend a significant amount of time trying to pre-certify exams and procedures for their patients,” Dr. Cabbabe added. “They worry this can endanger patients who have illnesses requiring urgent diagnosis and treatment. Patients get frustrated waiting for approvals for these procedures and tests.”
Approvals often call for “peer review,” where the insurer requires that the practicing physician speak directly with the insurance company’s physician, who typically is paid by the insurance company to perform the review. Among those surveyed, 85 percent find the peer-review process very difficult or somewhat difficult. Most difficult is getting new technology pre-certified, with 93 percent finding it very or somewhat difficult. Another concern raised is that the physician reviewing the case frequently is not of the same specialty as the ordering physician.
“The comments we receive indicate that it often takes several attempts for the physician to reach the insurance company for peer review, sometimes involving lengthy waits on telephone hold or multiple calls,” Dr. Cabbabe said. “Often, the information provided is the same as what the physician’s staff provided. All of this takes time away from the physician’s day, using time that otherwise could be spent caring for patients.”
Dr. Cabbabe added, “Through this survey, physicians told us they spend more time fighting insurance companies than they spend fighting disease, and that shouldn’t be the case.” He also noted that physicians object to the level to which insurers insert themselves into a patient’s care. “One respondent asked why do we allow people from the insurance company who have never seen or examined the patient to determine the care they should receive?
The ease of obtaining insurer approvals varies some by type of service, according to the survey results. Surgical procedures (3.61), radiology procedures (3.36) and rehabilitation services (3.21) are more likely to be approved promptly. Pain management (2.85), medications (2.96) and devices (3.04) encounter pre-certification delays more frequently.
Another physician concern noted in the survey results is insurance company mergers, about which 93 percent somewhat agree or strongly agree that “when health insurance companies merge, my patients’ outcomes are negatively impacted.” In addition, 80 percent somewhat agree or strongly agree that they have concerns about the narrowing of insurance networks causing their practices to be dropped from insurance plans.
Ratings do not vary widely among individual insurance companies in St. Louis. Overall, Healthlink (3.37) and SSM Health Exclusive Choice (3.30) achieved the highest composite scores, while Mercy Health (2.99) and Aetna/Coventry (2.90) scored worst.
The survey was conducted by the Prell Organization in September and October and received 302 responses, representing 5 percent of St. Louis-area physicians. Respondents were evenly split among areas of practice, with 36 percent coming from medical specialties (e.g., cardiology, gastroenterology), 34 percent from surgical specialties (e.g., orthopedics, general surgery), and 30 percent from primary care. As far as practice location, 55 percent are from independent private practices, 36 percent practice in a hospital system, 12 percent work in academic settings, and 2 percent in other locations. Respondents represented a range of years in practice, with 46 percent practicing 20 years or less, 24 percent practicing for 20 to 29 years, and 30 percent practicing for 30 years or more. Forty percent of responding physicians are current St. Louis Metropolitan Medical Society members.
The St. Louis Metropolitan Medical Society, representing medical and osteopathic physicians in St. Louis city and county, works to advance strong patient-physician relationships and quality health care through advocacy, communication and education. Founded in 1836, the Medical Society is affiliated with the Missouri State Medical Association and the American Medical Association.