The Challenges of Medical Care When Insurance Algorithms Rule

In the first portion of Episode 187, “Good and bad algorithms in the practice of medicine” (May 19, 2022), Walter Bradley Center director Robert J. Marks and anesthetist Dr. Richard Hurley discussed where algorithms help in medicine… and where they don’t. In this portion, they turn to how to get good medical care when you are dealing with an insurance company as well as medical staff and institutions. The two types of institution are, as we will see, very different.

Before we get started: Robert J. Marks, a Distinguished Professor of Computer and Electrical Engineering, Engineering at Baylor University, has a new book, coming out Non-Computable You (June, 2022), on the need for realism in another area as well — the capabilities of artificial intelligence. Stay tuned.

This portion begins at roughly 7:31 min. A partial transcript and notes, Show Notes, and Additional Resources follow.

Dr. Hurley talks about battling algorithms while trying to provide spinal surgery for patients with back pain:

Richard Hurley: They’ve had all kinds of “conservative care.” Ultimately, I may decide to do a procedure called median branch blocks or facet nerve injections, where we anesthetize the joint to see if function and pain improves. Now, once I request that, I have to send all of my notes, all of my imaging, everything, to the insurance company. And we might hear back from them in a week. So when a patient comes in and they expect care at that particular time, I can’t even offer it to them because it has to be approved.

Dr. Richard Hurley

And they [the insurance company] ask 15 different questions that my nurse will fill out electronically. But if she misses one — just one — or if she doesn’t dot the I’s and cross the T’s, then it gets denied. And the insurance companies have people who are not experts. They’re not nurses. They’re not even medical assistants. They are people who have been trained to read notes and then look for reasons to deny it.

Robert J. Marks: Well, this is the whole point, right? They’re following fixed rigid algorithms which do not allow the flexibility that you need.

Richard Hurley: Right. And the companies that do this have just blossomed with managed Medicare. Everybody thinks managed Medicare is like standard Medicare. That’s false. You have standard Medicare — but then you have to pay for your supplement, which is 20% of the care. Sometimes that costs more than the standard Medicare. Managed Medicare gets rid of all that. It’s just one fee. So if an insurance company like Blue Cross, Blue Shield, or Aetna is involved, they can make money if they deny services or postpone them.

(Dr. Hurley explained that when insurance companies turn down payment for procedures, he is allowed to appeal and, in his case, 100% of them are approved over time. So it is a waiting game.]

Robert J. Marks: So they’re reasonable but you really have to go to battle with them. How much time do you spend battling the insurance companies?

Richard Hurley: Not all insurance companies require prior authorizations but all managed Medicare does. And almost all primary insurance does but standard Medicare does not. So if you have standard Medicare with a supplement, there’s no pre-authorization… People who sign up for managed Medicare are not aware that they’re going to be plagued with pre-authorizations.

Dr. Robert J. Marks

Robert J. Marks: The funny thing is, I go in for procedures every once in a while and I’m given an estimate of what the insurance company will pay. Invariably, almost 100% [of the time] I get a bill for extra money. In other words, the medical doctor doesn’t know how much the insurance company will pay. They guess — or maybe they have a standard reimbursement that they quote me — but it never seems to be enough.

On one occasion I did get a check back that I paid too much, but that was a rarity. And that seems to me to be frustrating and a very bad algorithm, if you can’t decide beforehand, what a procedure’s going to cost.

Richard Hurley: Absolutely, and you don’t see that. In medicine, if there was no insurance and everybody paid cash, you’d have the prices written outside on a billboard.

Robert J. Marks: So the insurance companies’ algorithms are, let me use the word, brittle. You can’t crack them. You can’t go outside of them. And that certainly must be frustrating. On the other hand, we know that we need algorithms because there needs to be some sort of constraint in terms of containing cost. So Richard, how could it be fixed?

Richard Hurley: The state of Texas came up with, in the last legislative session, the Golden Rule. Essentially, if a physician had six months of care in which … virtually 90% of the requested authorizations were passed, then they would get a gold card. For the next six months, they can go ahead and schedule the procedure without getting authorization. It was supposed to have happened by, I think, the beginning of the year. But, interestingly enough, insurance companies have been trying to tack on different rules…

Robert J. Marks: Now, when you or your assistant or your nurse talks to the insurance companies, I guess one of the things that must be frustrating to you is that you, as a physician, are arguing with somebody who is trying to follow a strict algorithm, but has no medical experience.

Richard Hurley: Correct.

Robert J. Marks: Yet you say that most of your controversies are concluded in a happy way. So how do they get around the algorithms? Are you given exemptions from the algorithm or what?

Health insurance business

Richard Hurley: Well, hopefully that’s going to happen. In other words, maybe one day I’ll have a gold card. I don’t know.

I doubt that [will happen for] interventional pain physicians, because the problem with chronic pain is that everybody’s going to be a patient at some time or another. You will be. I will be… Everybody copes with it differently. But authorizations for certain medications, like CGRP inhibitors for migraine, cost $600 a month. And if you think about how many millions of patients have that, and you just dump that on the system, insurers would really struggle. And I understand that as well…

But the biggest problem I have is when I do a pre-authorization and it gets rejected, I go to appeal and go back and review my notes. And then I talk to the doctor there [at the appeal board]. The reason I win is because they didn’t read all the notes. They didn’t look at the MRI report.

They just missed it. And so I always ask them, “Why do you ask for us to send all the notes on the patient when you don’t read them?” I mean, it doesn’t make any sense.

Robert J. Marks: Oh, my gosh. The gold card, the more I think about it, the better idea it is. I like the idea of vetting physicians to give them more flexibility in what they do.

Another question I have, what is the difference between the different insurance companies? They all have these brittle sort of algorithmic criteria that they impose on the practice of medicine. Are there some which are better than other ones?

Richard Hurley: I’m not the expert in that, so I can’t tell you. We have less problems if people can afford standard Medicare with a supplement. When they get to “Medicare” age, I just encourage them to go that route. Even though you’re healthy, and even though you may not have used a lot of healthcare, you don’t know what the future’s going to bring. Even though you may be paying more, that’s the way I would go. Managed healthcare changes. What I mean by that is, Blue Cross/Blue Shield may have this criterion to do median branch blocks on a patient this year — but next year they’re going to change it.

Health insurance, tax concept on blue background

Robert J. Marks: Really? So the rules keep changing?

Richard Hurley: Oh, the rules change on the first of the year. They publish it. You might get to see it; you might not. And then all of a sudden you haven’t met that criterion, so it gets denied.

Robert J. Marks: How do you play the game without knowing the rules?

Richard Hurley: Well yeah, it’s really funny. You get denials, and then all of a sudden, you find out what the new rule is. Then you start adjusting your notes so that it fits their criteria. Those are kinds of things that we, as physicians, get really frustrated with. And those rules seem to be quite arbitrary. And they’re based on what they perceive as abuse, where all of a sudden this procedure’s going way up. And is there any reason for it? There may not be, and it may be abuse. But they’re penalizing all the other patients involved by changing the rules and not letting us know.

Robert J. Marks: A number of different companies give health insurance. Is there a monopoly, happening unsaid, where the rules for all of these insurance companies are roughly the same? The reason I ask this is, it seems that if there were true competition in the spirit of free enterprise, in the spirit of capitalism, between the different healthcare insurance providers, there would be a competition to give the best service. Which would be a motivation to sharpen their algorithms to make them more user-friendly to the physician.

Richard Hurley: I feel sorry for the lay person who doesn’t know a lot about medicine and how healthcare is done. Because you basically would think, “Well, I’m probably not going to buy the cheapest, but I’m certainly not going to buy the most expensive. And so I’m going to try to hit one in the middle of the road.”

If you ask a lay person in the United States what a pre-authorization for healthcare is, many patients might know, but most people don’t. And they don’t ask that when they go to get their plan. But in answer to your question, all the managed care providers use other companies to develop these algorithms to decide whether a procedure is medically necessary or if it’s experimental.

Robert J. Marks: Really? So they farm it out then.

Businessman holds the model of business, made from wood blocks. Alternative risk concept, business plan and business strategy. Insurance concept.

Richard Hurley: Right. And one of the largest companies is a company called eviCore. They manage 100 million Medicare Advantage patients. 100 million.

Richard Hurley: So I usually have to talk to eviCore. By the way, I have the right under the state of Texas, to talk to a peer. In other words, if my nurse sets up an appeal, she’ll say, “Now, Dr. Hurley does want a pain physician, board certified, who he’ll talk to.” And by law, they have to get that… In other words, I don’t have to argue in front of an oncologist or a primary care [physician].

Robert J. Marks: It’s peer review, if you will?

Richard Hurley: Right. It’s a peer review. If that ever changes, it’s time for me to retire.

Robert J. Marks: Okay. You mentioned previously, and I thought this was interesting, if we didn’t have insurance, the price of every procedure of every medicine would be printed on a billboard… Do you think that this price is going to be higher or lower if we didn’t have insurance?

Richard Hurley: Anytime the federal government gets into anything, the price goes up. You know that as well as I do… the price goes through the roof. And that’s because you’re very inefficient if you run anything from Washington DC, as opposed to doing something local. The state can do things cheaper than the federal government can do. And the local governments can do things cheaper than that. Or a private institution, like Baylor or whatever…

Robert J. Marks: I’m wondering if some of these different insurances were localized more and separated, like the divestiture of the Bell Systems Labs, where they broke up the company, that maybe we would get a better deal?

Richard Hurley: Well, the drugs that we use in the United States cost X dollars. The same drug in Canada cost 75% less because they have one payer and that’s the Canadian healthcare system. They buy all the drugs and they dispense them.

Robert J. Marks: Okay, so that’s a vote for socialism.

Richard Hurley: It is, and I’m not saying… But what I’m saying is, is there any reason why two years ago the price of insulin doubled and tripled and quadrupled? I mean, I don’t know. I don’t know that information. But then if the federal government goes in and says, “Okay, you can sell insulin, but you can only sell it for $35 a vial” how many people are going to play with that? I don’t know. I don’t have the answers in terms of the cost and how to control it.

All I know is everybody wants American healthcare and they come here in droves to get it. It’s still the best. And I think it always will be as long as we do it. And it’s not truly private. There’s a mixture of the federal government, state government, private enterprise and all that other stuff.

But algorithms in healthcare to help patients get better, whether in surgery or on the floor, are designed by physicians to help other physicians or providers to do things. And the algorithms for insurance companies are done differently.

Robert J. Marks: So that’s another interesting question. This eviCore, do you know to what degree they employ physicians to set up these policies?

Richard Hurley: I have no idea, but they must have hundreds, if not thousands of physicians that work either part-time. But please don’t give me that job. I don’t want to have to answer the phone and listen to appeals. I couldn’t do that job.

Robert J. Marks: The interesting thing is probably all those medical doctors make these recommendations and it’s eventually decided by a bunch of guys with MBAs.

Richard Hurley: It may be true.

Robert J. Marks: Yeah, that would be my hunch. Okay. Any final words, Richard?

Richard Hurley: No, I’m glad we had a chance to at least talk about this. I doubt that the public is aware of the algorithms that are involved in pre-authorization of patients for procedures or medications.

Frequently they blame the physician. Okay. Why are you not getting this done? Why am I having to wait? They don’t realize that the hangup is not at the office where you see your physician. But it’s in computers and insurance companies that actually want a say in whether you can have that care or not.

My suggestion for people who are buying health insurance is: How much pre-authorization is this product going to have? And I might run away from it.

Always ask “What, is the procedure? Do I have to have pre-authorization to be admitted to the hospital? Do I have to have pre-authorization for this type of surgery? All of those things.

Here is the first portion of this episode, with partial transcript, links, and notes:

Algorithms in medicine: Where they help … and where they don’t Removing creativity, nuance, and insight from medicine may result in cheaper care but not better care. Surgery robots help many surgeons today but, as anesthetist Richard Hurley explains to Robert Marks, insurance algorithms on who gets care can flop badly.

You may also wish to read Dr. Hurley’s thoughts about addiction:

Opioids: The high is brief, the death toll is ghastly. Fentanyl has medical uses in, say, open heart operations where the patient is on life support; otherwise, it is a one-way ticket off the planet. Anesthesiologist Richard Hurley tells Robert J. Marks how Fentanyl affects the brain and why the street version is so deadly.

and

What anti-opioid strategies could really lower the death toll? Anesthetist Dr. Richard Hurley discussed with Robert J. Marks the value of cognitive behavior therapy — reframing the problem. Life expectancy in the United States is decreasing due to opioid deaths, though the problem is now primarily street drugs, not medically prescribed ones.

Show Notes

  • 01:59 | Introducing Dr. Richard Hurley
  • 02:10 | Do Surgeons Pay Royalties for Procedures?
  • 02:59 | Coffee and Calamari
  • 04:45 | Spinal Surgeries
  • 07:31 | Algorithms in Medicine
  • 12:40 | Do Drug Companies Interfere With the Practice of Medicine
  • 19:26 | How Can the Current System Be Fixed?

Additional Resources

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