For the past year, I’ve worked as a third-party medical insurance reviewer. I’ve reviewed a variety of cases for pediatric clients as it relates to their hospital stays, therapies, and prior authorization for medications as medically necessary. I have come in direct conflict with physicians, insurance companies, and the reviewers for this company. It was during my review of a pediatric case today I had the following thoughts. Before I go on, I wanted to thank the original provider’s office for having an electronic medical record! Big hugs, big thanks, and praise the Lord that I did not have to decipher reams and reams of handwritten notes. They performed a proper medication reconciliation so I could easily find the date that the medication in question was started and when the medication had been switched to something else. I could easily see all the cool new ICD 10 codes.
But what really confused me was how the insurance company did not leverage the information that was right at their disposal. They have access to medication utilization and refill data. They also have access to unscheduled office visits, urgent care and ER visits, and inpatient admission data.
. As a provider, I know that a mark of well-controlled for asthma is no nighttime symptoms, decrease or no utilization of rescue inhalers, only come in for follow-up visits every three months, no exercise intolerance, they can keep up with other children, no significant exacerbations requiring systemic steroids, and no inpatient admissions and definitely no intubation’s. I also am well aware of the standards of care surrounding this disease and if a patient is well controlled based on the previously mentioned criteria, it is not in the best interest of the patient to change a patient’s regimen solely based on changes in insurance formularies.
For the insurance company, if you were to evaluate the aggredated data as far as medication refills, unscheduled office visits, unscheduled ER in urgent care visits, you will find out that there are a subset of patients that are actually under excellent control you may want to offer them an exception to random formulary changes based on that data. Also can you imagine the goodwill you can bestow to the provider and family members because you proactively present the providers a list of their patients that are not going to require prior authorization and utilization reviews because you’ve given them the information up front and they will not have to be interrupted for and utilization review? And also the goodwill bestowed on the families who will have peace of mind that the insurance company is not going to randomly stop coverage of a medication that keeps their son or daughter healthy? Why can’t the companies agressively and proactively reach out to the patients and the providers and basically say we’ve noticed that this patient has been on his medication and has exhibited really good control and here is an incentive honorable mention in the insurance plan newsletter, reduction in premiums or coupons for medications, or higher payment to providers or performance bonuses? I believe these small gestures cost less than payments for catastrophic illness and repeated ER visits. Also, if I were the insurance company I would try to find out and replicate whatever this provider is doing to keep his patients compliant, his practice in the management of these patients and distributing this information to other providers in your network. What if the insurance companies had a Goodwill metric that there are exceptions that take in health of a patient on a non-approved regimen and long term cost savings if they were to continue on that treatment? Although goodwill is an intangible asset, it still is a undeniable and underated contributor to the bottom line of healthcare institution.