The letter concludes by reiterating the MMA's request that Medica suspend its high-tech imaging utilization review program and instead engage in a community-wide effort to understand and address the issue of imaging costs as they relate to the rising costs of health care.
March 30, 2007 Charles J. Fazio, M.D., M.S.
Chief Medical Officer and Senior Vice President.
Medica.
PO Box 9310.
Minneapolis, MN 55440.
Dear Dr. Fazio:
Since the introduction of Medica’s high-tech imaging utilization review program in January 2007, the Minnesota Medical Association (MMA) has received an extraordinary number of complaints (over 100), a sampling of which we would like to bring to your attention. Specifically, our members have raised concerns about burdensome time requirements, general administrative hassles, coping with poorly trained staff, and inconvenience for patients that combined have the potential to adversely impact patient care. These programs are affecting Minnesota health care providers, support staff, and office personnel across all care settings and all clinic types.
MMA members and their staff have stated that the time required to prepare for and complete the consultation process is too burdensome. While Medica maintains that the administrative burden is low and the process takes between 5-7 minutes, the information submitted to the MMA suggests that the amount of time devoted to this non-patient care function is, in fact, very significant.
Among the specific complaints received by the MMA are:
“In a specialty practice (neurological surgery) in which most of the diagnostic and follow-up evaluation of patients requires CT or MR imaging (i.e., patients with brain tumors require regular follow-up imaging; patients with unruptured, intracranial aneurysms and AVMs require regular follow-up MR, CT or conventional angiographic imaging). There is little controversy for the majority of my patients. A recent follow-up scan for a brain tumor patient required over an hour of nurse time for approval.”The utilization review process is also causing a variety of administrative hassles, as indicated in the following complaints:
“A middle-aged woman with biopsy proven breast cancer was referred for breast MRI to address inflammation noted on biopsy material and spread/lymph node involvement for purposes of treatment planning. Her scheduled follow-up appointment with oncologist was in two working days. Medica replied that authorization would require ten working days and the scan was denied (until authorization could be granted).”
“We have encountered MANY questions, call backs, phone calls with this system. They have called back on almost everything we have requested with further questions. We do CT scans of sinuses here in our clinic and that has created problems; sometimes we don't get the authorization for more than 24-hours. I have spent upwards of 45-minutes trying to get something approved.”
“As a scheduler for three of our six clinics, I have just completed a 53-minute call to Medica, only to get reference numbers for three CT studies on one patient and will now need to wait for them to review, approve and fax me the approval or denial of these exams.”
“I am finding that I need to schedule patients a few days out for a scan or MRI at another facility so we have time to get the pre-authorization. Our clinic tries to take care of patients in a very timely way so this is frustrating.”
“Now, the patient does not stay in the office and get scheduled. The patient leaves the office, and if the test is approved by Medica then the patient needs to be located which takes usually one to two days and multiple phone calls and voice mails and calls back and forth and often missed messages. It is an inefficient waste of our office staff time.”Complaints received by the MMA about poorly trained staff at HealthHelp – staff with limited knowledge of medical terminology and staff suggesting contra-indicated alternative therapies – are very alarming. Consider the following:
“I am a rural family practitioner. Our access to CT and MRI is limited to a truck that comes in once per week. It is difficult enough to coordinate the patient and the truck at the same time, many times these studies have to be coordinated with specialists who come to town to staff outreach clinics. Our patient population is elderly and cannot go out of town.”
“A frustrating issue is calling for prior authorizations for patients whose plans do not need a prior authorization and the only way you know this is to call. Staff spends time on the phone or the internet providing the information only to find out that the patients plan does not require prior authorization. Again, time consuming.”
“Our main concern is the lack of a streamlined process to do these reviews with Medica. Our nurses are spending hours on the phone with Medica trying to get these MRIs and CTs authorized. We had a patient in our clinic in Duluth from International Falls who needed an urgent MRI and who waited over three hours trying to get the test authorized with Medica. Their website was active on March 1st.When one of our UR nurses tried to use it Medica's system told her the patient was not eligible for the imaging request. The nurse did however verify the patient’s eligibility online and by phone, and both agree the patient is eligible.”
“The person that answered the phone and asked me the screening questions had very little knowledge of medical terminology, requiring me to explain and/or spell many of the words.”
“I ordered a Brachial Plexus MRI that was not preauthorized. After 3 days and over 1 hour on the phone, eventually a person at Medica admitted that authorization for the test was not forthcoming because she did not know what the brachial plexus was. The Brachial Plexus was not on some list in front of her. She had no physician internally to whom she could refer the case in a reasonable time frame. She did not care that we were looking for a cancer under the armpit and that the family was rather anxious.”
“I find that most of the Medica personnel I have spoken with on the phone have limited medical knowledge; certainly not a lot of knowledge about radiographic exams.”
“The second instance involved an MRI of the forearm given clinical weakness and a positive EMG. I was looking for an impingement along a nerve. The request was sent 2/16; a nurse called for further information on 2/16 wondering whether NSAID’S had been tried or plain x-rays taken or blood work had been obtained. I told my secretary to call the nurse back and tell them those were inappropriate questions given the clinical situation. A radiologist subsequently called on 2/21 with further questions…He understood exactly why I wanted the test and agreed to the authorization.”
We appreciate the opportunity to share some of the feedback the MMA has received from practicing physicians and their staff detailing their experiences with Medica’s high-tech imaging prior authorization process. We can not stress enough the intensity of the near-universal negative reaction MMA members have expressed to the approaches taken to date to address the use of high-tech imaging services. Far from becoming part of the “background of their daily work” as you assert, Minnesota physicians continue to struggle with the administrative hassles and patient care implications of this program, as well as the variable approaches taken by other health plans in the community.
The overwhelming reaction from MMA members on this issue has led the MMA, as you know, to introduce legislation (HF2003/SF1752) that would establish a moratorium on prior authorization programs until a comprehensive study of the factors driving high-tech imaging utilization could be conducted. Such a study is critical in Minnesota and the MMA would hope that you would support this important effort.
The MMA is committed to addressing the rising costs of health care and has expended considerable energy and resources to provide leadership aimed at reforming our health care system, including the fundamental flaws in current payment systems. We appreciate the identification of high-tech imaging as an issue meriting attention, but the MMA will vigorously challenge any program that serves to increase the burdens of clinical practice, add administrative complexity and cost to the system, or potentially decrease the quality of health care provided to Minnesotans. To that end, we again ask that Medica withdraw its high-tech imaging utilization review program and instead support a community-wide effort to understand the issue and to develop reasonable and targeted solutions.
Sincerely,
G. Richard R Geier Jr, MD, MMA President
Michael Ainslie, MD, Board of Trustee Chairman
Robert K. Meiches, MD, MBA, Chief Executive Officer