Insurers Continue to Delay, Restrict Needed Care for Area Patients; Problem Worsens, According to Medical Society Survey
Physician frustration grows; delays can force prolonged use of narcotics and other medications and put patients at increased risk
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St. Louis-area patients continue to experience delays and restrictions in receiving needed care due to insurance company practices in pre-certifying coverage, and the problem has worsened in the past two years, according to a new survey of the area’s physicians conducted by the St. Louis Metropolitan Medical Society. The survey is a follow-up to a similar survey conducted in fall 2016.
Physicians surveyed in 2018 gave insurers a composite score of 3.02 on a scale of 1 (worst) to 5 (best) for the promptness and ease of obtaining pre-certifications, also referred to as “prior authorizations.” This is a statistically significant decline from the mean score of 3.19 achieved in the 2016 study. In the pre-certification process, 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.
“The overall rating of insurance company performance translates to a letter grade of ‘C.’” explained Christopher Swingle, DO, 2018 SLMMS president, “and it’s a slightly lower ‘C’ than achieved two years ago. Physician assessment of insurers’ performance is declining, while their frustrations with the process of obtaining pre-certifications are on the rise.”
Respondents were given statements to associate with the numerical rating scale to determine their ratings regarding ease of pre-certifications for a variety of different services by various insurers. Responses range from 1, equaling “rarely to never approves prescribed procedure, test or medication” to 5, equaling “promptly approves.” The middle score of 3 represents “may approve after delay or physician involvement.” Physicians were asked which insurance companies and for what specific functions do they most often seek pre-certification. They were then were prompted to rate those companies and procedures accordingly.
The rank-order of pre-certifications for all types of care surveyed did not change over the two years, with medications (69%) and diagnostic radiology tests (67%) still the most required for pre-certification. However, the mean promptness ratings for all types of care declined from 2016 scores, with the largest declines in pre-certifications for radiology procedures (falling from 3.36 to 3.13) and diagnostic radiology tests (from 3.20 to 2.95).
Summarizing the comments from physician respondents, Dr. Swingle said, “St. Louis-area physicians are telling us that pre-certifications can be a major hurdle in the practice of quality medicine. Unfortunately, the situation is not only not improving, it’s actually getting more cumbersome. Insurance company practices not only delay or deny necessary care, but contribute to prolonged use of medications and narcotics, ultimately putting patients in danger or increased risk.”
There is also general agreement among physicians that restrictions imposed by insurance companies negatively impact their ability to practice medicine. Nearly all respondents, 95%, somewhat agree or strongly agree with the statement “I have had to alter a patient’s treatment plan because of restrictions from an insurance provider.” This percentage is up slightly from two years ago. Eighty-nine percent of those surveyed somewhat agree or strongly agree with the statement “My ability to practice medicine appropriately is influenced by insurance company policies on pre-certification.” However, concerns about narrowing networks and being dropped from insurance plans expressed by physicians declined from two years ago.
When questioned about the relative ease or difficulty of working with insurance companies, physicians reported that “getting new technology pre-certified” still poses the greatest amount of difficulty, with more than half describing this process to be “very difficult” (54%) and almost all respondents finding it at least “somewhat difficult” (93%). Less difficult, although still presenting barriers, is “the peer-review process” (90% of respondents said it is at least “somewhat difficult”) and “getting standard procedures pre-certified” (68%). Physicians rated “dealing with imaging centers” as more easy (52%) than difficult (48%), a positive change from the 2016 results.
As in 2016, composite ratings of individual insurance company performance in the St. Louis area (on a 5-point scale) do not vary widely, ranging from Aetna, lowest at 2.88, to Exclusive Choice (SSM Health), scoring the highest at 3.35. Essence (3.17) and Anthem (2.95) have statistically significant lower mean scores in 2018, which means they are now slower to give approvals. Healthlink (3.12) and Cigna (3.03) have also declined over the two years, but the changes are not considered significant.
“Physicians also report the multiple attempts and lengthy waits on hold for themselves or their staff to secure pre-approvals,” said Dr. Swingle. “This continues to take away from valuable time spent caring for patients. Doctors also object to the level at which insurers get involved in patient care, without ever spending time with the patient. We need to use this data to bring forth positive change in the practice of medicine, to reduce physician frustration and burnout, and no longer restrict needed care for patients.”
The survey was conducted online for the St. Louis Metropolitan Medical Society by the Prell Organization between April and June 2018 and received 290 responses, representing about five percent of St. Louis-area physicians.
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.