The Introduction

Pre-Authorization: The great divide and the great opportuity.

I think that the murder of Bryan Armstrong, the CEO of United Healthcare, is a terrible tragedy of epic proportions. However, it is also a big event, from which we as humans can start a conversation about Insurance, Pre-Authorizations and Denials.

Now while I realize this is a contentious topic and people will have very strong emotions and probably biases, it is a very useful point to start in any discussion of the healthcare insurance industry because all the elements of discussion of systems are there and because the emotions make this a popular modern drama,and probably everyone has a opinion.

I call it a drama because it is filled with strong narratives, and the important trifecta of any drama; a hated evil villian (healthcare insurance companies), an innocent victim (patients) and a valiant hero (physicians).

Please note tht I portray the characters in this drama, in this fashion, not to make light or levity of a serious situation. But instead to show how some of our feelings and biases start off from this very simplistic framework. Which is how our brains have evolved to deal with life in a what has always been a dangerous environment; earth.

Our brains developed in an envirnment where a human needed to quickly decide what animal would try to eat you, and what animal could be eaten. Then the human makes choices based on this most basic assessment in order to survive.

This type of thinking helped our human ancestors survive, but now it is inadequete to deal with the complexities of modern life. So we must realize our weakness of automatically framing things as friend or foe, and pause to more carefully analize our environment and those in it. It is a more modern and more complicated world. And since humans use stories to pass down complex ideas, I think a now is a good time for a good story to ilustrate on of the most important points of this essay.

The body of the story

The bird, the cow and the cat.

Part 1: the bird

Once upon a time, a little bird decided not to fly south for the winter with the rest of his flock on the appointed day for the journey. The little bird lingered in the summer home of his flock for a few weeks longer. Then one day he awaoke to the chill and snow of winter. He then tried to fly south for the winter, but winter soon his body and wings were covered with snow and ice. he stopped flying and fell to earth; a frozen, near dead bird. And as he lay on the ground, and he realized that his end was near, he thought of the folly of his decision to delay his flight south. If only he could get a second chance.

Part 2 the cow and the cat

Now as luck would have it, a cow decided to cross the field where the little bird lay on the ground, and it slowly walked past the bird, with it's nose in the snow, looking for grass. Then in a act of sheer luck and perhaps humiliation, the cow passed over him and pooped on the bird. A huge hot pile of hot poop.
And as the bird lay there with the steaming poop covering it completely the bird suddenly began to feel life in his feet and his wings. The hot poop warmed his frozen body and brought him back from the brink of death. The bird sat up and stretched it's wings and feet and flapped his wings and he suddenly was filled with hope. It had stopped snowing and perhaps he could try to fly south again, now that he had a second chance. The bird was so happy he began to sing.

Meanwhile a cat was patrolling the field looking for field mice and heard the bird sing. The cat went over to the pile of poop and began to lick the bird, removing the cow poop and discovering a little bird. The cat then killed the little bird and ate him.

Part 3 :The Moral of the story:
The moral of this story is not everyone who shits on you is your enemy. Not everyone who takes shit off you is your friend. And when your in deep shit up and fighting for your life, keep your mouth shut and be quiet.

Pre-Authoriation:

Part 1: Things are not always what they seem

In the story above, the bird was not the victim, the birds plight was one of his own doing. He was not an innocent bird trying to fly south for the winter. He was a bird who didn't leave in the fall, when the rest of the birds left. He stayed until winter was present and suffered the consequences of his behavior. So not everyone we think is an innocent victim is really an innocent victim.

In the story above, the cow shit on the bird, which is a terrible thing. But since the bird was frozen and dying, the hot poop actually brough him back to life. The cow shitting on the bird would actually have saved the birds life and given him a second chance to fly south for the winter. But the bird started singing and the cat found him. So not everyone we think is the bad guy, is actually the bad guy.

In this story, the cat licked the bird and took all the poop off him. Which you would think is a good thing. But in actuality the cat had ulterior motives, and the cat killed the bird and ate him. So we learn that not everyone we think is the good guy, is actually the good guy.

Pre-authorization:

Part 2: Things are not always what they seem.

First, the patient.
In the case of Pre-Authorizations the three characters in this drama; patient, physician and insurance company are not always what they seem.
In the case of patient, they are not always innocient victims of the villian; the insurance company. An important statement to make at this point is that the customer, i.e. the patient is not always right. Patients sometimes are upset about being denied surgery that they don't need, or that hasn't been proven effective for their condition.

Let;'s start with the first item; the patient is not always right.
For example; a patient may complain that their greedy insurance company denied their claim to save money. I would never say that never happens, but I would also say that sometimes a claim was denied because it was not in the patient's best interest to have a surgery and that is an important thing to talk about.

First of all surgery is not a magic bullet. Ask the millions of Americans who have had back surgery, and who are still in chronic pain, and some of whom have worst pain after their surgery then before. Disheartening.

Second of all, ask the thousands of patients who had a knee replacement surgery to manage their chronic knee pain, only to replace the old pain, with a new pain.
Disheartening.

Quite honestly I could go one for a while citing examples of where surgery didn't work, and the patient is worse off then they were before.

Now does that mean that surgery never works?
No, of course not.
Do some of these patients do wonderfully?
Yes. Pain gone, Disease banished.

There are many good outcomes from the surgical management of disease.
But like everything else in life it depends.

Ask yourself will you get rich buying Bitcoin?
It depends... What price did you buy it? How long do you intend to hold it? How much tax will you have to pay on it's sale?

It sounds like a straightforward question, but actually it is not straight forward abecause it depends. It is the same with surgery. It depends on right patient, right proceedure, right time and right outcome.
All surgeries have the ability to heal or fix your problem, but all surgeries can have complications, and the complications can be worse then the disease.
So from a logic standpoint, no one should undergoe a surgical procedure, which has the potential, no matter how small, to cause a stroke, heart attack, death or permanent disability, without first trying non-surgical metods, if they exist.

This is not an attempt to scare you. But the fact is that people die every year having elective surgeries that perhaps they didn't have to have at all. And that is indeed a tragedy. Even something as simple as carpal tunnel syndrome surgery is not appropriate for every patient with carpal tunnel disease. Because many of these patients will completely recover using a splint and some ibuprofen. Some may require steroid injections.

So this is where patients may be wrong about the insurance company. Their surgery was denied because they didn't have a trial of conservative therapy. Usually for 6 weeks.
Are there exceptions for patients who are really bad, and don't want to wait six weeks?
Yes.
One of the reasons to have medical doctors involved in Pre-Authorizations is for the exceptions. A patient whose surgery is denied because they have had a nerve conduction study, a Medicare requirement, not an insurance company requirement, it is to document the nerve was diseased before operating on it. Which seems reasonable when you think about it.

If the patient has other signs and symptoms of nerve disease on exam, and these are documented in the office notes sent with the request, then yes, this patient can have their surgery approved without six weeks of splinting, based on physical findings of advanced nerve damage.
So yes there are exceptions.

Next the Physician.
The physician is often portrayed as the White Night or Hero in this play, fighting on the side of the patient, against the evil insurance company.
This portrayal also needs to be questioned.
While there are any fine physicians and excellent surgeons, these are humans, and they get paid to perform operations. So there is an inherent conflict of interest when you get paid for operating.

There's an old saying; To the man whose only tool is a hammer, the whole world looks like a nail.

So I will be blunt, not all surgeries which are requested are the best available therapy for the patient. There are many illnesses and injuries, which the human body is capable of healing itself. So the purpose of Pre-Authorization can be a form of Quality Assurance, as in assuring that the patient gets the best treatment for their illness or injury. That could be splinting, casting, or surgery. But the right therapy for the right patient, at the right time is the goal.

So yes there are heroe in medicine, but not all physicians are heroes and some are villians.

Waste, Fraud and Abuse
We all want our government to be efficient, and that means government officials must look for waste, fraud and abuse. This includes un-necessary surgeruies, medical treatments and tests.

Last, insurance companies.

It is a popular narrative that insurance companies are the villian in the insurance drama, we call modern healthcare. I understand this sentiment, and it is a popular and pervasive feeling for a reason; it is frequently true.
Shocking.
Some of you are looking at this screen and saying did he just say that some insurance companies are villians? Yes I did.
Some of you are thinking, but didn't he say things are not always what they seem?
Doesn't that mean he is going to defend insurance companies?
No.
I am not here to defend insurance companies, physicians or patients.
Sorry.
I am here to defend the truth.
And the truth is that some insurance companies are villians, some doctors are villians, and some patients are villians.

The truth is that where there is smoke, there is fire, and some insurance companies do some pretty villinous stuff.
But not all of them, and not all the time.
The truth is there are good guys, bad guys, and in between guys, when you look at patients, physicians and insurance companies. What sorts them out are facts, truth, and reason.

So I am asking you to look at Insurance Pre-Authorization and see it for what it can be; quality assurance and a chance to choose the right therapy, for the right patient at the right time.

This gives the patient the best healthcare outcome; a living, healthy individual who was returned to health and full function by whatever therapy was chosen.
Thats why we are discussing this and why I want you to understand it. So seize the opportunity to learn and understand. Ask questions, research ideas and remember anyone can be a villan and anyone can be a hero.

#newlion