Cardiologist at the Scripps Memorial Hospitals, Assistant Professor of Internal Medicine at Western University.
As a cardiologist and aspiring economist focused on healthcare policy, I'm deeply concerned by the rise of Medicare Advantage plans. On the surface, these plans promise to deliver Medicare benefits more efficiently through private insurers. But a closer look reveals how prior authorization requirements in Medicare Advantage often restrict medically necessary care, to the detriment of patients and the healthcare system. The numbers tell a very scary story: In 2021, Medicare Advantage plans denied 6% of over 35 million prior authorization requests, frequently overruled on appeal. 82% of prior auth denials are overturned when appealed, suggesting many should not have been denied to begin with. Only 11% of patients appeal denials, often unaware of their rights or daunted by the complex process. The economics are clear - plans have a financial incentive to restrict expensive care via prior authorization, as they are paid a fixed amount per patient. Denying care boosts their bottom line. The human costs are also apparent, as patients face delayed or foregone treatment, worse health outcomes, and surprise bills for denied services. Doctors and hospitals must divert resources to fighting denials. Medicare Advantage has strayed from its promise, prioritizing profits over patients. Healthcare leaders and policymakers must scrutinize these practices and enact reforms. Protecting access to care should be the priority. Our system fails when it rewards insurers for saying "no" to patients in need. The new rules are a start, but robust enforcement will be key. Patients deserve a system that provides fair, timely access to quality care - not one that rations it to pad corporate profits. It's time we rethink the trajectory of Medicare Advantage, before it does irrevocable damage to Medicare and the patients it serves.
Buck Bard
2mo
I read up on the history of Medicare Advantage and I can't stop laughing. Congress actually thought that transferring some of Medicare to the private insurance companies would actually save money. Well, that's what they said. I'll bet my life savings the insurance lobby wrote the bill.
The "Advantage" is only to the insurance company.
The needless burden of extensive appeals adds to the cost of care both directly and indirectly. Physicians and their office staff are tied up with the appeals process while patients wait and often pass out of the window for timely care. Time for a hard look at a deliberate menace.
Victor Sloan
1mo
When is prior authorization not a roadblock? While the stated intention is to ensure appropriate therapy it seems likely it’s more about getting people to give up rather than give them the appropriate therapy.
Scott Duliban
2mo
Sad….
Prior authorizations are a massive source of friction in health care. Bob Sutton
Dmitry Yaranov
2mo
Spot on! Extremely important piece!
Mike Godfrey
2mo
Well said.
Area Vice President of Sales - Western US
2moThis is the reality of healthcare today! We deal with heart failure patients trying to receive care only to have to fight insurance companies for approvals that for straight Medicare are not required upfront as long as they meet the reasonable and necessary standard set by the physician as it should be. These plans are not aligned with patient’s interests.