If We Want to Be Heard, We Must Speak Up

Jill Gilbert, MD

We use scientific truths in our profession every day. These truths allow us to meaningfully discuss the data supporting our decisions and prognoses with our patients. However, we are faced with a rise in false flags and half-truths that increasingly involve the medical field. If we do not question these halftruths and learn to trust what we see with our own eyes, we are at risk of becoming complicit in a message that ultimately undermines our ability to treat our patients safely and effectively.

However, we are pulled in so many directions that we often see the onslaught of these halftruths as far too great to overcome—certainly far too great for us to address. This includes falsehoods from other parties telling us what we should practice. As providers, we have too long ceded our place at the table when it comes to the art and practice of medicine.

We talk about that art with patients, but modern practice also involves managing the finances of patient care. We spend a great deal of time justifying things we know to be true in our practice: that step therapy is not OK for patients with cancer, that prior authorizations (PAs) delay care.

This is where you come in. As fellows, you are well versed in caring for patients, but you may need time to adjust to managing the challenges involved in the actual practice of medicine. In your professional career, you will be immersed in half-truths, and you will need to speak up.

You may call me a radical, but believe it or not, I see myself as a rule follower. That said, I also recognize that having a seat at the table means not just passively retweeting or liking a social media post or complaining about processes behind clinic doors.

Collectively, we have power, and it is past time that we use our clout to make tangible change. Some issues that started as public health benefits may actually be public health menaces, and it is incumbent on all of us to recognize that and take action.

Let’s look at PA, as defined by the American Medical Association (AMA):

“Prior authorization is a health plan costcontrol process enacted by insurance companies by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. On the surface, the prior authorization process is an important tool to help cut health care costs and these measures are appropriate.”¹

However, the AMA also noted that physicians and their staff spend an average of 13 hours per week completing PA requirements for patient medicines, procedures, and medical services. In one AMA survey, 93% of responding physicians reported that the PA process delays patient access to necessary care. And some of these delays can be lengthy, with 26% of physicians stating that in the prior week, they waited an average of 3 or more business days to receive PA decisions. Furthermore, 82% reported that delays in the PA process led to patients abandoning treatment.²

In fact, the American Society of Clinical Oncology (ASCO) has sent out a call to action based on recent findings from the US Office of Inspector General (OIG) report showing that 13% of PA denials in the Medicare Advantage (MA) program were for service requests that met Medicare fee-for-service coverage rules. Requests for imaging services, stays in postacute facilities, injection medications, and cancer care were often denied despite meeting Medicare coverage rules. We are constantly told that PAs cut down on spending. Instead, PAs can delay or prevent delivery of important, evidence-based patient care.

To publicly expose this issue, the New York Times published an article in April 2022 entitled, “Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds.”³ I encourage all of you to read it. I’m glad a reporter at the Times wrote this piece, but the question is: Why didn’t we write it ourselves?

For too long in this field, we have buried our own observations and accepted others’ opinions about how we should best practice and provide for our patients. It was easier for us to accept these opinions than to protest. But we have to ask ourselves whether these opinions are still delivered with the noblest of intentions, or do we choose to believe that because it is easier?

I urge you to undertake the process of visible and courageous support of the truth. Tweet and tag key stakeholders, write letters to your elected officials, and align with ASCO or other professional organizations to make tangible change.

As health care providers, we are motivated to diagnose and provide treatment when we observe a threat to health and well-being. Consider the aforementioned half-truths as threats to health. As health care providers, we have more to offer than thoughts and prayers. We have our collective voice. This is our swim lane. Take the time to use it.

References

1. 2016 AMA prior authorization physician survey. American Medical Association. January 2017. Accessed May 18, 2022. https://bit.ly/3zvuVN5
2. 2021 AMA prior authorization physician survey. American Medical Association. February 21, 2022. Accessed June 2, 2022. https://bit.ly/3tcN4Lw
3. Abelson R. Medicare advantage plans often deny needed care, federal report finds. New York Times. April 28, 2022. Accessed May 18, 2022. https://nyti.ms/3llhMhp

Jill Gilbert, MD, is a professor of medicine and vice chair for Professional Development in the Department of Medicine at Vanderbilt University Medical Center.