Psychiatrists Waste Millions of Hours Obtaining Prior Auths

By J. Wesley Boyd, M.D., Ph.D.
Psychology Today, Almost Addicted blog, May 14, 2013

My colleagues and I recently tabulated how long psychiatric patients who were deemed in need of inpatient admission — overwhelmingly because of suicidal thoughts or plans — stayed in the emergency department prior to being hospitalized, as well as the amount of time that the emergency department psychiatrists spent obtaining authorization from the patient’s insurer.

We found both lengthy waits for severely ill psychiatric patients in need of immediate hospitalization as well as time consuming prior authorizations required by insurance companies and published our findings in Annals of Emergency Medicine.

In our study psychiatric personnel spent, on average, 38 minutes on the telephone getting authorization. In 10% of cases it took more than one hour to obtain insurance authorization; in one case authorization took five hours of psychiatrist time. On top of the time required to obtain authorization, psychiatric patients who need admissions wait a long time for inpatient beds to open up. The total time that patients remained in the ER in our study averaged 8.5 hours.

Our data don’t include a handful of patients who boarded in the ED over the weekend while waiting for an inpatient bed to become available for them and also excluded uninsured patients and those with Medicare, which doesn’t require prior authorization.

A much larger study published just before ours found even longer wait times — more than 11 hours while awaiting placement into an inpatient facility.

Out of 53 requests, we had only one prior authorization request denied, so basically the process of calling the insurance company, relaying patient information, and obtaining her authorization to pay for admission, is a needless, time consuming process given that the end result — namely, the insurance company saying they will in fact pay for the admission — is a foregone conclusion provided I jump through the proper hoops.

Imagine if women in labor required this kind of authorization or if children with ruptured appendices did? There would be a public outcry and the practice would end immediately.

Given that there are approximately 2.5 million inpatient psychiatric admissions annually in the US, if two-thirds of them require some form of prior authorization (which is likely an underestimate), then roughly a million hours of time annually is wasted by psychiatric clinicians obtaining these authorizations. Add to that the many day hospital admission and psychiatric medication requests that also require prior authorization from insurance companies, and the total number of psychiatric clinician hours spent on the phone asking for authorization of service is staggering.  

Just today, for example, I spent 25 minutes on the phone obtaining authorization for a psychiatric medication I prescribed for a 50-ish-year-old professional male. Knowing the call would take a chunk of time, I thought about not making the call and just having him pay out of pocket for the medication instead of taking my time to make the call, but I just couldn’t bring myself to concede defeat to his insurance company so, ultimately, I made the call.

This is a travesty. It is demoralizing to psychiatric clinicians. For me to have to calculate whether my time is worth it for an insurer to pay for medications it is supposed to pay for is pathetic.

It also testifies to the fact that psychiatric patients are singled out for this kind of scrutiny because they are vulnerable and often unwilling to publicly advocate for themselves, the way that pregnant or pediatric patients and their allies might. I’d wager that insurance companies hope to profit off this vulnerability, given that overworked clinicians might opt to, if they are on the fence about how to proceed, do something other than admitting their patients given the hassle of seeking authorization. My co-authors and I call this “rationing this by hassle factor.”

The humanity of societies is judged by how well they take care of their most vulnerable, and we undoubtedly need to do better.  Health insurance needs to provide real coverage and assurance to those in need, not set up roadblocks to needed care that deter clinicians from seeking care when it is life-saving.

If we had a health care system that was not profit driven — an improved Medicare for all would be ideal — then I’d wager such impediments to urgent care would not be present and patients could receive the care they need without unnecessary hurdles for healthcare clinicians to jump through, set up only to generate greater profit for insurers.
 
References:
Amy Funkenstein, MD, Monica Malowney, BA, J. Wesley Boyd, MD, PhD.  Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency Department Length of Stay for Patients With Psychiatric Conditions.  Annals of Emergency Medicine, Volume 61, Issue 5, May 2013:  596–597

J. Wesley Boyd is on faculty at Harvard Medical School and is an Attending Psychiatrist at Cambridge Health Alliance and Children’s Hospital Boston.

http://www.psychologytoday.com/blog/almost-addicted/201305/psychiatrists-waste-millions-hours-obtaining-prior-auths