Dealing with red tape consumes clinicians’ time, poses danger to patients, researchers say
Medline Plus, March 25, 2016
(HealthDay News) — Children with severe psychiatric problems often have lengthy waits before they’re transferred from a hospital emergency department to a psychiatric hospital due to insurance companies’ “prior authorization” requirements, a small study suggests.
Mental health workers at one Rhode Island hospital spent an average of an hour on the telephone seeking insurance companies’ approval, the study authors reported. In one case, the researchers said approval took up to 4.5 hours.
“The majority of these kids are suicidal; a minority of them are homicidal. That’s as dangerous as having a burst appendix,” said study senior author Dr. J. Wesley Boyd, a psychiatrist at Cambridge Health Alliance in Cambridge, Mass.
All of the admissions were ultimately approved. This suggests that prior authorization appears to serve “more as an administrative hurdle,” the study authors wrote.
“This is rationing care by hassle factor,” said study lead author Dr. Amy Funkenstein, an assistant professor of medicine at Tufts University in Boston.
The study was scheduled to be published in a letter March 30 in the American Journal of Emergency Medicine.
Rhode Island allows prior authorization for any inpatient admission but prohibits its use for any type of emergency service, said Linda Johnson. She’s the operations director for the Office of the Health Insurance Commissioner in Cranston, R.I.
Currently, state regulators are combing hundreds of insurance company records to assess compliance with the state’s mental health parity law, she said. The question is whether a patient needing psychiatric hospitalization meets the definition of emergency, she explained.
Prior authorization assures that a patient is covered under a health plan, the requested service is a covered benefit and the most appropriate level of care is provided, explained Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness in Washington, D.C.
Patients may be better served in partial hospitalization or intensive outpatient programs, for example, said Greenberg, whose association members are mostly large insurance companies.
“You have to look at costs, too; let’s be honest,” she added.
Dr. Joseph Mawhinney, a San Diego-based child and adolescent psychiatrist, called the prior authorization process “a bureaucratic maze” wrought with wrong phone numbers, dropped calls and people at the other end of the line not having authority to make a decision, requiring a referral to someone else.
“It can go on and on and on. Meanwhile, you don’t have a decision or a placement,” said Mawhinney. He’s also a member of the American Psychiatric Association’s (APA) Council on Healthcare Systems and Financing, and chairs the APA’s Access to Care Workgroup.
Between May and October 2014, psychiatric clinicians at Hasbro Children’s Hospital in Rhode Island kept track of the time spent on the phone with insurance companies on behalf of kids in need of psychiatric admission.
Researchers collected paperwork on 203 patients aged 4 to 19. In more than half of the cases, hospital psychiatrists recommended admission due to suicidal thoughts or a suicide attempt. Other common reasons for admission included aggression (22 percent) and homicidal thoughts (10 percent), the study reported.
From initial contact with the insurer to authorization, phone times ranged from 3 minutes to 270 minutes, and the average amount of time spent on the phone was 60 minutes, the study found.
Based on total psychiatric admissions nationwide, that translates into more than 1.5 million hours of “wasted clinician time,” the researchers said in a Cambridge Health Alliance news release. Those hours translate into a staggering amount of wasted health care dollars — about $31 billion a year, the researchers estimated.
The average time cited in the study is actually shorter than the median 79-minute “boarding time” from emergency department to hospital bed, said Clare Krusing. She’s a spokeswoman for America’s Health Insurance Plans, in Washington, D.C.
While not addressed directly in the study, the authors questioned whether prior authorization for psychiatric admissions violates federal mental health parity legislation. Under federal rules, managed care protocols, such as prior authorization, must be applied equally to mental health and medical/surgical care.
“They [health insurers] use the same process for medical necessity review across all services,” Krusing said.
She also noted that the study “completely ignores any details about what information the clinician provided to the insurance company as they were reviewing the request.”
Boyd believes health insurers continue to unfairly single out psychiatric cases for prior authorization.
“Somehow or other, the insurance companies continue to flout the intent behind parity, and I’m not quite sure how they continue to get away with it,” he said.
“Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient admission,” Amy Funkenstein, MD, Stephanie Hartselle, MD, J. Wesley Boyd, MD, PhD. The American Journal of Emergency Medicine, May 2016, Vol. 34, Issue 5, pp. 915–916. DOI: http://dx.doi.org/10.1016/j.ajem.2016.02.027
SOURCES: J. Wesley Boyd, M.D., Ph.D., psychiatrist, Cambridge Health Alliance, Cambridge, Mass., and professor of psychiatry, Harvard Medical School, Boston; Amy Funkenstein, M.D., assistant professor of medicine, Tufts University, Boston; Linda Johnson, operations director, Office of the Health Insurance Commissioner, Cranston, R.I.; Pamela Greenberg, president and CEO, Association for Behavioral Health and Wellness, Washington, D.C.; Joseph Mawhinney, M.D., child and adolescent psychiatrist, San Diego, member, Council on Healthcare Systems and Financing, and chair, Access to Care Workgroup, American Psychiatric Association, Arlington, Va.; Clare Krusing, spokeswoman, America’s Health Insurance Plans, Washington, D.C.; March 3, 2016, news release, Cambridge Health Alliance; March 30, 2016, American Journal of Emergency Medicine.