Your Doc Wants to Give You the Care. You Want the Care. Insurers are Iffy…..the Prior Authorization Nightmare

A huge headache for the healthcare industry is “prior authorization” – the bureaucratic nightmare of getting approvals from insurers for what doctors say is needed care.

CAQH,  a non-profit Washington, DC-based alliance of health plans and trade associations, released a report last month –  detailed by Health Data Buzz  – that shows how these prior authorizations  have hamstrung the move toward using electronic records, with a resultant significant loss of clinician time and spiraling monetary costs.

That is merely the latest in a string of concerns about payer prior authorization requirements, which increases doctor practice burdens and overwhelms patients, according to multiple organizations.

Major  healthcare associations say there has been a big push the past two years to change the prior authorization system, though progress comes slowly. At this point, there are many pleas for reform and  organizations insist they are  banding together to try to make changes happen.

A HeavyWeight Outcry

Earlier this year, the American Medical Association,  Medical Group Management Association  and other groups issued  an urgent consensus statement that outlined what they termed a shared commitment to establish industry-wide improvements  to reduce the onerous prior authorization process in which approvals are needed by health plans, benefit managers, and others. Last week,  CAQH added their major concerns.

The groups  expressing dismay include other powerhouses, insurers among them:  the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, among others.

In March, an American Medical Association  survey showed that more than nine in 10 physicians reported that prior authorization programs “have a negative impact on patient clinical outcomes.”

The problems, MGMA says,  are wrapped around agreements between health plans and participating physicians in which “the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures.”

Physicians have to divert their attention from clinical and  administrative staff time – as well as resources – to work on submitting preauthorization requests for services, MGMA says.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications and medical devices ceaselessly question the judgment of physicians, resulting in less time to treat patients and needlessly drive up administrative costs for medical groups,” said MGMA’s President and CEO Halee Fischer-Wright, MD, in a statement.

Impact on Patients

According to referralmd, while many preauthorization approvals are used for  expensive drugs, generally “66% of prescriptions that get rejected at the pharmacy require prior authorization.”  It adds:  “Not only is this negative for pharmaceutical organizations, most importantly this causes frustration to patients who don’t get the medication that could best treat their condition, or who don’t get any therapy at all.”

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike,” AMA President Andrew W. Gurman, MD, said in a statement. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior-authorization programs.”

The groups wanting change have outlined a set of 21  principles aimed at helping patients receive what they term timely and medically necessary care and medications and reduce the administrative burden.

Making Things Better

Among other things, they have several suggestions for improvement.

For instance, they said there can be a regular review of medical services and prescription drugs that are subject to prior authorization requirements that would more easily  identify those which may not be necessary because of “low variation in utilization or low prior authorization denial rates.”

In addition, they added:  “effective communication channels between health plans, health care providers and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rational and program changes”

“Clearly, industry action on prior authorization is needed,” wrote CAQH in a letter last week. “Substantially improving prior authorizations on behalf of the industry ranks among our highest priorities in 2018.”

Impact on Electronic Record and Efficiencies

According to its 2017  CAQH Index adoption of the standard prior authorization transaction by health plans and providers could result in savings of $6.84 per transaction, one of the most significant per transaction opportunity areas, it said.

But the “proportion of prior authorization transactions using that standard actually declined by more than 10 percentage points” from the previous year’s Index report. According to the CAQH Index, providers conduct 77 million prior authorization transactions manually each year. It said: “Providers could save more than $3.20 per transaction and health plans could save at least $3.64 per transaction with fully electronic prior authorizations.”

The goal of the coalition is to shed a “bright light on today’s prior authorization requirements and offer tangible recommendations for improving the current process.”

Let’s see how far, with its list of principles, and the glare of the spotlight, these organizations can go to change a process that is harming many.

— Joe Cantlupe, HealthDataBuzz.


Healthcare’s Fumbling Over Electronic Records. Or Should They Just Re-Think It?

Think about it. Phones. Faxes. Even email.

A bit rusty, no?

No. This is 2018 healthcare, when it comes to physician offices  handling administrative and insurance claims transactions.

A non-profit healthcare alliance last month found in a significant study that healthcare is losing a big opportunity to save billions of dollars by its failure to switch over fully to electronic claims- related business processes among providers and insurers. The business of healthcare in the U.S. can and should be simpler, less burdensome, and, yes, perhaps most of all, less costly. And it’s not happening.

The CAQH a non-profit Washington, DC-based alliance of health plans and trade associations, uses words like “modest progress” in the transition from manual to fully electronic administrative transactions, but also  “backward,” and “no longer sufficient.” The organization also has been known as the Council for Affordable Healhcare Quality Inc.

“There are billions of dollars at stake. The electronic transactions should be more efficient and accurate and less of an administrative burden,” says Reid Kiser, interim director, CAQH Explorations, and lead researcher for the report. “They support optimized workflows for providers and the focus on the patient that health plans want to deliver and allow them to drive toward population health,” Kiser says. Kiser is an independent consultant with Kiser Healthcare Solutions, LLC.

Physician use of electronic inquiries rose by  6 percentage points for inquiries related to claim status, and 3 percentage points for eligibility and verification inquiries in 2016 compared to the previous year, according to  CAQH, which works to share initiatives to streamline costs and improve the business of healthcare. Its CAQH Index was released in June.  (In its study, CAQH also reviewed dental practices).

At a time they are trying to serve more of their patients, providers are spending up to 30 minutes on manual tasks, like making phone calls, sending faxes – faxes! – and mailing correspondence. Thirty minutes may not seem like much, but when you have only so minutes in a doctor’s office, that means a lot.

That’s a problem, Kiser says. “Once (patients) move over to a new health plan that information is essentially lost if (a patient) comes back to the health plan a few years later. From the (CAQH) perspective, it’s manual work that the provider has to do,” he says.

Beyond adoption levels, the index estimates the cost and time associated with conducting administrative transactions. On average, each manual transaction costs the industry $4.40 more than each electronic transaction and requires five more minutes of provider time.

Think of how many we’re talking about: The annual volume of administrative transactions reported by medical plans increased substantially, rising by 25 percent, from 4.8 billion in the prior year to more than 6 billion.

Going in Reverse: Or Not?

Whatever gains have been made in recent years are actually going backwards in the world of automation of claims related to business transactions. The savings potential from automating clams management increased to $11.1 billion annually in the most recent CAQH Index, with the focus on more than $7.5  billion for medical providers and $2 billion for dental providers and the remaining $1.7 billion for health plans.

That is an increase over $1.8 billion in potential savings from the previous year. The index is described as the industry source for tracking health plan and healthcare provider adoption of electronic administrative transactions for both medical and dental care.

Portals: “Accelerate or Hinder Progress?””

There’s a lot of data here, and CAQH points to one of the possible problems in evaluating the use of full electronic records, and that’s portals, the secure online websites that allows insurers, providers and patients get more involved in care.  While they are certainly helpful,  each one involves  a serious amount of work for physicians, including paper-pushing, such as clinical paperwork needed to support claims.  So it’s seen as being partially electronic in the CAQH Index and that raises all kinds of questions, including: is portal use really a bridge toward better use of electronic record use, does it hold it back: is it advancing, or not?

While the report says portals offer health plans a “highly automated solution,” some provider groups indicate that portals also create “substantial administrative burdens.”

“This is because portals require the provider to sign on and navigate a different online system for each health plan with which the provider is contracted,” the report says. “Also, portals lack advanced features common to clearinghouses and clearinghouse-integrated practice management systems, such as the ability to validate claims and check eligibility and benefits prior to patient appointments.”

That effect,  says CAQH: “may accelerate or hinder progress.”

So is the use of portals for physicians and dentists actually hurting them in using overall electronic records?

“We’re not at that point of our research to clearly understand that,” Kiser says. “Are we getting to fully electronic or are we at the point in the market just accepting all of these partially electronic, or portal transaction?”

Reid Kiser

Reid Kiser, lead researcher for CAQH report

An estimated 925 million manual transactions and nearly 14 billion electronic transactions were conducted by medical plans, a 38 percent increase over the prior year.

This is because a much higher number of administrative transactions were conducted using costlier manual transactions. This includes the portal transactions.

One study estimate with costs associated with healthcare billing and insurance-related administrative activities to reach $315 billion by this year, nearly as much as the 10 highest spending state Medicaid programs paid combined in 2016 to provide care for more than 46 million beneficiaries.

In a call to action, the CAQH Index concludes that the “ the relatively slow, incremental process reported in recent years of the transition from manual to electronic administrative transactions is no longer sufficient.”

It proposes that “industry participants strongly support provider access to robust electronic data interchange systems and expand the understanding for reasons behind increasing portal use, and urges all stakeholders to embrace the transition to fully electronic transactions.”

The research concluded that few vendors support all of the most essential electronic administrative transactions.

Adjustments Needed?

“We’ve seen tremendous cost and time savings from our investment in technology,” said Jody Meza, practice administer, Alpine Medical Group LLC in a statement. “We feel it’s important to do everything we can to deliver care as efficiently as possible for our patients, and automation of our administrative transactions is one way that we deliver on that goal.” — Joe Cantlupe

Note: The 2017 CAQH Index is the fifth annual report assessing industry progress to reduce the use of manual transactions and eliminate cost. Data was submitted from health plans covering more than half of the commercially insured U.S. population in the year studied based on enrollment reported in “AIS’s Directory of Health Plans: 2017.” Medical health plans contributing data covered 155 million lives, or approximately 51 percent of U.S.

It represents collaboration between healthcare providers and health plans. The report reflects data from participating health plans representing 112 million enrollees – almost 45 percent of the privately insured U.S. population – on more than four billion transactions. A range of healthcare facilities and provider practices participated in a day collection process conducted on behalf of CAQH by Milliman Inc.

CAQH Report’s Data:

  • Claim submission had the highest overall adoption level among the electronic transactions studied, at 95 percent – a 1 percentage point increase over the prior year.
  • Fully electronic coordination of benefits/crossover claim transactions increased 19 percentage points to reach 75 percent.
  • Fully electronic eligibility and benefit verifications increased 3 percent over the previous year, reaching 79 percent.
  • Fully electronic claim status inquiries rose 6 percentage points, from 63 percent the previous years to 69 percent. The volume of phone inquiries and the concurrent need for manual labor remained stable.
  • Claim attachment, with a fully electronic adoption level at 6 percent, showed no measurable change as compared to the previous year.
  • Electronic funds transfer adoption for claim payment decreased slightly, falling to 60 percent from 62 percent the previous year.
  • Fully electronic remittance advice transactions increased slightly, increasing to 56 percent, one percentage point over the previous year.
  • Fully electronic remittance advice transactions increased slightly in the 2017 index, rising to 56 percent, one percentage point over the previous year.
  • Fully electronic prior authorization transactions declined by 11 percentage points.
  • Use of partially electronic transactions rose by 10 percentage points.






Tough Pill to Swallow? Pfizer Trumped On Price Hike …

A day after President Trump lambasted Pfizer on a previously announced July 1 price hike on three dozen drugs, the pharmaceutical company backed down following what  the company CEO described as an “extensive discussion” with the president.

Trump said he spoke with Ian Read, the head of Pfizer, and the Health and Human Services Secretary Alex Azar and the drug company decided it was  “rolling back price hikes” that Pfizer already put in place.

Trump has been fairly consistent on admonishing the pharmaceutical drug-makers on their extravagant pricing. For the administration, its blueprint to reduce prescription drug costs is one of its hallmark efforts. Among other things, the administration  is seeking a “more competitive pharmaceutical marketplace” and “bring down out-of-pocket costs for Americans, Trump’s plan states.  For critics, the blueprint has been too loosely defined, and not tough enough.

In the meeting with the Pfizer chairman and CEO, the blueprint apparently took center stage.

“Just talked with Pfizer CEO and @SecAzar on our drug pricing blueprint,” Trump tweeted. “Pfizer is rolling back price hikes, so American patients don’t pay any more.”

“We applaud Pfizer for this decision and hope other companies do the same,” he added in the @realDonaldTrump tweet. “Great news for the American people.”

A day earlier, Trump scolded the company, saying it should be ashamed “that they have raised drug prices for no reason.”

“They are merely taking advantage of the poor & Others unable to defend themselves while at the same time giving bargain basement prices to other countries in Europe & elsewhere. We will respond!….” Trump tweeted.

After the meeting with Trump today,  Pfizer ‘s  Read said the company would “defer the company’s price increases that were effective on July 1.” That would give the president “an opportunity to work on his blueprint to strengthen the healthcare system and provide more access for patients,” Read said.

The company said it will maintain prices on three dozen drugs to their pre-July 1 levels as soon as technically possible. And, the prices will stay in place until the president’s blueprint goes into effect or the end of the year – whichever is sooner.

“Pfizer shares the President’s concern for patients and commitment to providing affordable access to the medicines they need,” said  Read.

— Joe Cantlupe


You Take Medications. You Take Herbs. Do They Mix?

One of the most important things you should consider when are taking medications, herbs or just about anything is how they interact with each other, and whether they can have complications that can harm you.

The danger is that with different types of medications even regular doses may become an overdose, depending on the interaction.

It’s important that everyone learns about their medications and become aware of the herbs they use, the supplements they take, and their response to them. It is best to check with responsible professionals and providers.


Some of the herbs used in Chinese medicine may be safe, but others can interact with drugs and have serious side effects or be unsafe for people with certain medical conditions. Some of the most serious drug interactions involve prescription medications and supplements.

That is becoming increasingly important as the popularity of herbal medicine increases. The World Health Organization estimates that 80 percent of the world’s population uses herbal medicine.  Many Americans, not happy with Western medicine for their ailments, have turned to alternative and complementary medicine, studies show.


Herbal medicines used in Traditional Chinese Medicine are sometimes marketed in the U.S. as dietary supplements. The U.S. Food and Drug Administration regulations for dietary supplements are not as stringent as for over the counter medications. The supplements are not as likely to have the same regulations as those for over the counter drugs. Supplements are also not as likely to be listed in a database of drug interactions.

Herbal Supplements and Drug Interactions

Nearly 25 percent of U.S. adults report also taking a prescription medication with a dietary supplement, according to an American Academy of Family Physicians study. 

Herbal interactions with prescription medications can interfere with how the drug may be broken down in the body, enhance side effects of prescription medications, or block the intended therapeutic effect of a drug.

Herb-drug interactions are complicated because many chemical components can be involved, and these compounds may possess diverse pharmacological activities, according to one study of the issue. 

The interactions potentially cause changes in drug levels and drug activities, which can sometimes have dire consequences.  Even though herbal supplements may be from plants, the ingredients can be chemical-related. As a result, herbal supplements may have drug interactions, not only with each other, but food or alcohol. And there may be no safety warnings so it may be difficult for someone to know if there is an interaction.

Different kinds of drug interactions

Some supplements, such as St. John’s Wort and Goldenseal, are known to cause drug interactions. As a result, they should be avoided with any pharmacological products.

Yet some supplements may cause interactions with some medications, but are safe with others, such as curcumin, Echinacea, garlic, Asian ginseng, green tea extract, and kava kava.

The kinds of interactions

Drug interactions can be in both pharmcokinetics and pharmacodynamics terms. Pharmacokinetics, sometimes described as what the body does to a drug, refers to the movement of drugs in, through and out of the body. Pharmacodynamics is the reverse: what a drug does to the body, such as the biochemical and molecular impacts.

Herbs may affect the behavior of a drug used at the same time by changing their absorption, distribution, metabolism and excretion.

Contamination of herbs

The National Center for Complementary and Integrative Health says there have been reports of Chinese herbal products being contaminated with drugs, toxins or heavy metals not containing the listed ingredients.

The Chinese herb ephedra (ma huang) has been linked to serious health complications, including heart attack and stroke. In 2004, the FDA banned the sale of ephedra-containing dietary supplements, but does not include Traditional Chinese Medicine remedies.

Interaction Examples

There are a host of interaction issues involving herbs and pharmaceuticals, with many related to bleeding, according to

Among the herbs which could have potentially negative impacts in interactions with drugs:

Evening Primrose Oil

The flowering plant Evening primrose is known by other names such as Oenothera biennis, scabish, or King’s cure-all. Drugs or herbs that have the potential to thin blood may have a reaction with Evening Primrose Oil.

American Ginseng

Ginseng has been used for many purposes, ranging from stress to endurance.  There are many different kinds of ginseng, but American ginseng has a blood thinner impact and may decrease the effectiveness of blood-thinning medications, and also should not be used with anticoagulants.

Ginkgo Biloba

Ginkgo Biloba has been used for dementia, Alzheimer’s disease and related ailments, but it may impact patients who take blood thinners, diabetes drugs or seizure medications. Ginkgo has been known to have interactions with about 500 drugs.


Goldenseal, also a flowering herb, is used for a range of conditions, including cold, flu and skin ailments, but there are dozens of drug interactions linked with goldenseal.

Green Tea

Green tea has been used for many health related issues, such as being an antioxidant. But it should not be used in connection with some blood-thinning drugs.

Getting advice from healthcare providers

Healthcare providers can give the best advice for any serious health impacts from drug interactions.

Advice to providers

Clinicians have been told they should consult reliable dietary supplement resources, or clinical pharmacists or pharmacologists, to help assess the safety of specific herbal supplement – drug combinations.  Often, patients do not mention supplements they use to clinicians.


18 Herbal Supplements With Risky Drug Interactions, medically reviewed, L. Anderson, PharmD, Drugs.Com

Asher, G, Corbett, A, et al. Common Herbal Dietary Supplement-Drug Interactions. 

American Family Physician. 2017. July 15; 96 (2): 101-107.University of North Carolina, Chapel Hill, NC.

Singh, A, Zhao, K. Herb-Drug Interactions of Commonly Used Chinese Medical Herbs. 

International Review of Neurobiology. 2017. 2017;135:197-232. doi: 10.1016/bs.irn.2017.02.010. Epub 2017 Apr 14.

The Controversy Over Kratom and… Opioids

Editor’s Note: From my piece last month at  HCPnow

As the U.S. struggles with an opioid epidemic, government officials, doctors and patients are confronting drugs too heavily used and sometimes too often prescribed.

Everyone is searching for alternatives to opioids for patients, many of whom are coping with intense pain. An estimated 91 million people were prescribed opiate painkillers in this country, and 2 million people suffer from substance abuse disorders linked to the medications, according to the National Institutes of Health. 

There are many people seeking different treatments, including supplements, as options to opioids, or trying to treat their withdrawal symptoms from opioids. One of the most controversial is a plant-based supplement, Mitragyna speciosa, known as kratom, derived from a plant native that had been used for thousands of years in Southeast Asia for pain relief.

Kratom has a history of being sold as a dietary supplement and has been used to manage pain. Mitragyna speciosa grows naturally in Thailand, Malaysia, Indonesia, and Papua New Guinea and has been used for many years in Southeast Asia as an opium substitute.

It’s from a plant, but it still can be an opioid, and produce morphine-like impacts, and that creates a dilemma.

Controversy Over FDA Warnings

Although it has been sometimes promoted as a natural alternative pain remedy, Kratom contains chemicals found in opioids, according to the federal Food and Drug Administration. While a few doctors have encouraged their patients to try kratom and their supporters enthusiastically support it, the FDA has been strongly against it.  Kratom has been usually taken as a powder, and the dosage has had stimulant and sedating properties. Kratom remains legal under federal law, but FDA officials want supplement companies to take kratom off the market. Inspectors also have been removing and destroying shipments of kratom from overseas.

The FDA has issued warnings about reports of injuries and deaths linked to kratom use. At least 44 deaths have been reported involving kratom since 2011, according to the FDA. Because of the reported health risks associated with its use, the FDA has banned the import of kratom.

Still, without question there has been an increase in use of kratom in the U.S, while government agencies have stepped up their concerns. A July 2016 report by the Centers for Disease Control and Prevention (CDC) noted that calls to poison centers about kratom exposure increased ten-fold from 26 in 2010 to 263 in 2015

The FDA also has linked kratom-containing dietary supplements to 28 cases of salmonella poisoning.  While supporters of kratom say there should be recalls of any product that contains salmonella, they oppose using the food safety investigation as a government step toward a mandatory recall of kraton products in the marketplace.

Medical Uses?

The FDA claims kratom is an opioid based on the agency’s extensive computer reviews that show its receptors in the brain also respond to heroin, morphine, oxycodone and other opioids.

FDA Commissioner Scott Gottlieb said there was no FDA-approved medical uses for kratom. “Claiming that kratom is benign because it’s just a plant is shortsighted and dangerous,” Gottlieb said in a statement.  “It’s an opioid. And it’s an opioid that’s associated with novel risks because of the variability in how it’s being formulated sold and used recreationally.”

However, a major supporter of kratom says it has a long history of acceptable safety consumer use as an alternative pain management therapy. In addition, it provides a “more favorable safety profile for consumers compared to more dangerously addictive and potentially deadly classical opioids,” says the American Kratom Association. 

The U.S. Drug Enforcement Administration had considered placing kratom in the same category of illegal drugs as heroin and LSD.  There were numerous protests about the proposal, however, including a letter signed by members of Congress, against it, forcing the agency to withdraw it. Some states, however, have taken steps to ban the supplement or classify it as a Schedule One drug, the same as heroin.

What’s Ahead

Gottlieb said the FDA is willing to evaluate further evidence involving kratom. He added: “The FDA stands ready to evaluate evidence that could demonstrate a medicinal purpose for kratom,” he said. “However, to date, we have received no such submissions and are not aware of any evidence that would meet the agency’s standard for approval.”


FDA and NIH statements on kratom:

American Kratom Association