Prior authorization is a contentious issue in spine care at the moment. Beginning July 1, CMS will require the policy for cervical fusion with disc removal and implanted spinal neurostimulators, which physicians say will further limit access to care.
Three spine surgeons expand on how increased prior authorization policies will affect spine care:
Note: Responses are lightly edited for style and clarity.
Question: How will increased prior authorization regulations affect spine care?
Lali Sekhon, MD, PhD. Nevada Neurosurgery (Reno): Prior authorization is a tool used by payers to ration healthcare and improve their quarterly balance sheets. I have worked in a world (Australia) where there was no prior authorization and decisions were left to the treating physician. It works. The American system enables profits for payers by using gatekeeper functions beyond treating physicians. The proposed prior authorization changes are meant to streamline decisions up to 72 hours, provide rationale for denials and improve transparency through providing metrics. This is good. The appeals processes, often needing submissions in writing, using 'peers' who are often not in the same specialty, or practicing and using nepotistic guidelines, also needs overhauling. The payers will not likely loosen much control but it's one step on a long road.
Thomas Loftus, MD. Austin (Texas) Neurosurgical Institute: Prior authorization is unjustified and unnecessary. Surgeons have trained for many years to make these decisions. They are required to complete extensive annual training to understand current indications for spine surgery. They take an oath to care for patients and are all taught not to offer 'unnecessary' procedures. If Medicare now feels they need to add an additional layer of bureaucracy to providing care, it would indicate that all of these other layers of training and bureaucracy are a failure. I would suspect the real reason for this decision is to create a backhanded way to simply reduce access to care for patients by further burdening their providers ability to deliver treatments. They call it cost control. Unfortunately, it is done at the expense of patients' health.
Adam Bruggeman, MD. Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): Spine surgery is perhaps most affected at this time with new regulations on spinal cord stimulation and cervical fusion from CMS and proposed changes to United Healthcare's prior authorization process requiring submission of imaging. This will undoubtedly lead to reduced patient access to surgery and delay necessary and appropriate care in the name of profit margins. Physician practices will be required to take on increasing staff costs to address these regulatory changes. It is imperative that we come up with solutions that streamline the process at minimal to no cost to providers' practices.