On Call: The Newsletter of the Alliance of Specialty Medicine

In This Issue:

Time is running out: patients and physicians brace for anticipated delays, and denials by UnitedHealthcare for endoscopies starting June 1

UHC’s inexplicable decision could lead to significant disruption of time-sensitive prescribed gastroenterology endoscopic procedures as a result of the insurer’s recent pledge to slash prior authorization requirements.

 

The American Gastroenterological Association (AGA) is profoundly alarmed and disappointed by UnitedHealthcare’s (UHC) recently announced prior authorization requirement for gastroenterology endoscopy services for all commercial plans, regardless of the outpatient location. Despite recently trumpeting its decision to cut down on its use of prior authorization, UnitedHealthcare’s expansion of prior authorization for most physician-prescribed endoscopy procedures—effective June 1—could disrupt time-sensitive care for millions of patients and create needless anxiety and delays for patients who may have cancer or other serious gastrointestinal conditions.

UHC’s new prior authorization policy will impact esophagogastroduodenoscopies, capsule endoscopies, diagnostic colonoscopies, and surveillance colonoscopies. These services are critical for the early diagnosis of life-threatening diseases such as colorectal cancer and for monitoring patients’ disease progression. The policy could cause care delays for high-risk individuals, deter patients from undergoing medically recommended procedures, exacerbate existing sociodemographic disparities in care and outcomes, and add to the growing administrative burden on physicians.

This new policy comes despite immense pressure from physicians, patients, lawmakers, and regulators to crack down on abusive prior authorization policies. The AGA has met with UnitedHealthcare to highlight the patient harm this policy will cause and continues to advocate for the policy to be reversed. Over 1,000 AGA members have sent letters to UnitedHealthcare’s CEO decrying the new prior authorization requirements and urging the insurance giant to reverse course for the sake of patient health and safety.

With the prior authorization policy set to start impacting patients on June 1, time is running out for UHC to rescind prior authorization for endoscopy procedures so that critical care is not delayed.

“After years of education, training, and experience, I know when one of my patients needs an endoscopy procedure. Yet, for some reason, UnitedHealthcare thinks it knows my patients—and their healthcare needs—better than I do,” Lawrence Kim, MD, AGA vice president-elect, a gastroenterologist in private practice, Denver, Colorado. “It’s unfathomable that insurance bureaucracy can put up red tape to block high-risk patients from accessing the timely care needed to potentially save lives. UnitedHealthcare recently announced it will slash prior authorization requirements for a wide variety of services, a goal we share. In order to truly put patients first, UHC must immediately reverse its dangerous policy so America’s millions of GI patients can access the care they deserve,” Dr. Kim continued.

UHC’s decision to expand prior authorization policies to include GI endoscopies is the latest example of insurance company overreach—often with terrible consequences for patients. According to the American Medical Association (AMA), one-third (33%) of doctors say prior authorization has led to a serious adverse event such as hospitalization, permanent disability, or death for a patient in their care. In fact, 46% of physicians report that prior authorization has led to immediate care and/or emergency room visits.

Doctors worry about accidents as Georgia seniors face delays getting routine cataract surgeries

 

Peggy Mitchell, 71, was having trouble driving at night, so she knew she could not wait any longer to have the cataract clouding her right eye removed. The lively Alpharetta resident had scheduled her surgery for Nov. 22, before Thanksgiving, and arranged for a friend to drive her to the surgery and back home. She had already had a cataract on her left eye removed the prior year without a hitch.   But her carefully laid plans ground to a halt at the last minute when her Medicare Advantage insurer, Aetna, denied approval for the routine, vision-saving surgery most older adults need at some point.

Mitchell and her doctor appealed the denial but did not receive a response in time, forcing Mitchell to postpone the procedure for more than a month until after Christmas. Mitchell’s ophthalmologist, Dr. Susanne Hewitt of North Fulton Eye Center, came into the office during her holiday vacation to perform the surgery for Mitchell and others.

What’s unusual about this situation is that Aetna Medicare Advantage requires prior approvals for cataract surgery only in Georgia and Florida, not in other states. Aetna Medicare Advantage plans covered 132,414 Georgians in 2022, according to the Kaiser Family Foundation (KFF).  Humana instituted a similar policy—only in Georgia—last fall. Humana Medicare Advantage plans covered 264,010 Georgians last year, according to KFF.

In contrast to the insurers’ Georgia policies requiring approvals, traditional Medicare – not run by insurance companies — does not require prior authorizations for most procedures, including cataract surgery.   Ophthalmologists and patients say Aetna and Humana’s policies delay care, put Georgia seniors at risk, and create burdensome administrative requirements, only for the surgeries to be approved in the end.

“What happened in that one month would be my question,” Mitchell said. “All that frustration and denial … I can’t tell you how it felt.”

As a self-described “healthy senior,” Mitchell had rarely used her Aetna health insurance and always paid her monthly premium. She was so certain her surgery would be approved that she started taking the expensive eyedrops needed to prepare. That proved a waste when Aetna did not approve her surgery for the originally scheduled date.

“I don’t know why me,” Mitchell said.

The answer to Mitchell’s question appears to lie in the contractual relationship between Aetna and iCare Health Solutions.   Back in 2021, Aetna began requiring prior authorizations for cataract surgery across the country. But after an outcry from ophthalmologists, Aetna reversed the policy last year – except for in Georgia and Florida.

“Aetna has been engaged in a 10-year relationship with iCare Health Solutions to manage ophthalmology and optometry services in Florida,” Aetna spokeswoman Kimberly Eafano said. “Almost two years ago, Aetna expanded this arrangement to include the state of Georgia, where iCare also has a community presence.”

Humana instituted a similar policy for its Medicare Advantage enrollees – only in Georgia – last fall. Humana said the unique Georgia policy is due to its relationship with iCare.

iCare did not comment despite multiple requests.

Georgia doctors are worried the delays put patient safety at risk. 

 “Any type of delay – even a few weeks or a couple of months – that’s usually a safety issue,” said Hewitt, Mitchell’s ophthalmologist. Many patients put off seeking treatment for cataracts because surgery, even a routine one like cataract removal, can be scary.

“I have patients that say they can’t see to drive on the road,” Hewitt said. “[They] follow the car in front of them. If that car turns and they’re not turning that way, they’re really in trouble because they can’t follow them anymore.” “If you have a patient who comes in as having a stated problem, and the examination backs it up, then we should act on that. We shouldn’t be telling them no, just for the sake of saying no.”

Dr. Chandler Berg, an Albany-era ophthalmologist, and president of the Georgia Society of Ophthalmology, echoed Hewitt’s concerns.

“Aetna’s policies have not improved and continue to limit patient access to surgical care,” Berg said. “I encourage patients with Aetna to switch to a different Medicare plan.”

The problem has drawn the attention of the state’s congressional delegation.  

 “These policies put Georgia [Medicare Advantage] patients at greater risk of falls and accidents as their vision continues to deteriorate while they wait for surgery,” the state’s Democratic representatives, led by Atlanta’s Rep. David Scott, wrote to the Centers for Medicare and Medicaid Services (CMS), the federal health-care regulator, last December.  “Georgia [Medicare Advantage] beneficiaries have faithfully paid premiums every month,’’ they wrote. “They deserve the same access to sight-restoring surgery that Aetna and Humana … beneficiaries have in other states.”

Five Republican representatives led by Rep. Buddy Carter of Savannah wrote a similar letter.

“Aetna’s and Humana’s prior authorization policies create obstacles to this common surgery for both patients and their physicians,” the GOP congressmen wrote.  But neither Carter nor Scott has received a response from CMS, their spokespeople said.

“CMS is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” a CMS spokesperson said in response to a query about the Georgia situation.

A proposed regulatory change that could take effect in 2024 would require Medicare Advantage plans to ensure that “people with Medicare Advantage receive the same access to medically necessary care they would receive in traditional Medicare.”  Meanwhile, the problems in Georgia continue. Gwen Brightman, a 67-year-old Aetna Medicare Advantage customer from Newnan, was forced to delay her surgery from Feb. 9 to Feb. 23 because the company did not provide her with timely approval.  Even the delayed surgery was approved at the last minute, said Brightman, who has a full-time job.

“I spent approximately two hours on the phone desperately trying to make the deadline and didn’t get the approval until the late afternoon [the day before],” she said. “This caused me extreme and unnecessary stress. Between the strain on my eye and the never-ending requests and requirements, I was a wreck. No one else should have to experience this nonsense.”

This story originally appeared in Capitol Beat News Service, a project of the Georgia Press Educational Foundation.

Specialtydocs Return to the Hill!

First In-Person Advocacy Fly-in since the Pandemic is set for July

 

The Alliance of Specialty Medicine will resume its in-person Advocacy Fly-In this summer, bringing over 100 specialists from across the county to Washington, DC, to meet with their members of Congress and advocate for greater access to specialty care.  The fly-in will take place July 17-19.

Since the COVID-19 pandemic, the Alliance has been conducting its annual fly-in virtually, visiting with health policy makers online.  However, the end of the public health emergency gives the Alliance physicians the green light to resume their regular routine when it comes to advocacy.

A significant focus of the fly-in will be Medicare payments to physicians.  For the past several years, physicians treating Medicare patients have endured arbitrary cuts to reimbursements while hospitals and Medicare Advantage plans have seen increases.  The Alliance will host a physician-led roundtable on July 17 in the Capitol to educate Members of Congress and their staffs on ways to stabilize the Medicare payment system.

There will also be a big push to reform the prior authorization system as more and more specialists are seeing a rise in prior authorization requirements for routine and preventative care.

An updated set of issue briefs will be posted on the Alliance website, specialtydocs.org, and we will also be posting updates on our social media channels, including Twitter (@SpecialtyDocs )and Instagram (#specialtydocs).  Follow along July 17-19 at #ASMFLYIN.

Retina Specialists’ Unique Imaging Tools Help Preserve Patient’s Vision

 

Advances in early detection and treatment of retinal diseases made possible by retina specialists can preserve sight and virtually eliminate vision loss. Retina specialists have access to highly specialized imaging equipment right in their office, allowing for earlier diagnosis, closer monitoring, and breakthrough treatment approaches that can help save sight.

Easy access to cutting-edge imaging technologies also allows patients to have all tests and imaging done to track the progress of their retinal condition in one location, eliminating the need to travel to a different medical office or clinic. Retina specialists strive to reduce treatment burden on patients and their families and provide a one-stop shop for diagnosis, monitoring, and treatment for everyone facing a retinal condition.

During May’s Healthy Vision Month, the American Society of Retina Specialists (ASRS) is educating the public about the advanced imaging techniques and technologies a patient may encounter during a visit with a retina specialist.

Common Imaging Techniques and Technologies Used by Retina Specialists

Indirect Ophthalmoscopy: A diagnostic technique used to examine the back of the eye, including the retina, optic nerve, and blood vessels. During the exam, the retina specialist shines a bright light into the eye from a special head-mounted device. The retina specialist then uses another lens, called a handheld lens, to magnify the image of the back of the eye and examine it in detail. Indirect ophthalmoscopy is performed in combination with other diagnostic tests to help diagnose and monitor eye conditions such as macular degeneration, diabetic retinopathy, and retinal detachments.

Fundus Photography: Fundus photography, and ultra-widefield fundus photography, use a specialized camera with a low-power microscope to capture a series of high-resolution images of the fundus, or back of the eye including the retina and macula, while a patient’s eyes are dilated. During this painless test, the patient is seated in front of a specialized camera and looks straight ahead while a bright light is shone into the eye. The camera then takes multiple images of the back of the eye, which are reviewed by the retina specialist for any abnormalities or signs of disease.

Optical Coherence Tomography (OCT): A non-invasive imaging technique that uses waves of light to capture individual images of cross-sections of the retina giving retina specialists a three-dimensional look at its structures and the ability to measure the retina’s thickness. The resulting images may be in color or black and white.

During the test, the patient is seated in front of a machine that looks like a camera and asked to rest their chin on a support to keep their head still. The patient’s eyes are then scanned with a special light, which captures images of the back of the eye. The results are available immediately which allows for prompt diagnosis and treatment.

Optical Coherence Tomography Angiography (OCT-A): A novel, non-invasive technique, OCT-A allows a close, three-dimensional look at the blood vessels and blood flow inside the retina and surrounding tissues. During the procedure, the patient is seated in front of a machine that looks like a camera and asked to rest their chin on a support to keep their head still. The patient’s eyes are then scanned with a special light, which captures images of the back of the eye, including blood vessels and blood flow.

Fluorescein Angiography/Indocyanine Angiography (FA/ICG): A diagnostic technique that uses a dye injected into the bloodstream and a highly specialized camera to record blood flow within the retina and the rest of the eye. After a patient’s eyes are dilated, a small amount of dye is injected in the arm or hand. The patient is positioned in front of a specialized camera and looks at a series of bright lights while a series of pictures are taken which shows the dye as it moves through the blood vessels in the retina.

Ophthalmic Ultrasound: Ophthalmic ultrasound or eye ultrasound uses high-frequency sound waves to create images of the structures inside the eye. During the non-invasive test, a probe is placed on the eye or eyelid, and the patient may be asked to move their eye in different directions. Ophthalmic ultrasound is useful in diagnosing and monitoring various eye conditions, including retinal detachment, vitreous hemorrhage, tumors, and other abnormalities.

For more information about retinal imaging, download our Advanced Retinal Imaging patient guide in English or Spanish or visit www.SeeforaLifetime.org.

A Night in the Life of a Busy Neurosurgical Resident

Abdul-Kareem Ahmed, MD, provides a poignant depiction of one night as a neurosurgical resident at the University of Maryland. Every patient’s worst moment is Dr. Ahmed’s every day.

 

“I CAN SEE BRAIN,” the trauma surgeon said. “This one’s for you.”

I was covering the neurosurgery night shift and had been seeing another patient in the resuscitation unit when the trauma team consulted me on a new admission.

Twenty years old, found down, and he appeared to have a hole in his forehead.

I examined him. He was in a deep coma, and his pupils were large, not reacting to light.

A rapid CT scan of his head revealed, in unfeeling white-and-gray pixels, a foreign object lodged in the back of his skull. A bullet, a vestige of a heinous act, had entered and torn through the middle of his brain, damaging life-giving structures. I reviewed this with my attending, but I knew. There was no neurosurgery, no medicine that could help him. He was devastated. The prognosis was grave. The trauma surgeon and I walked to the waiting area to talk to his mother and father, who had just arrived. They didn’t expect to be here, at this hour, for this reason. That time, before they heard what parents fear most, felt dilated.

We introduced ourselves. We asked what they already knew. I listened. After a pause, in plain language, I explained what had happened, how he was. You don’t forget a scream like that. It cleaves your soul. She just learned her son will soon be no more. His life had just begun.

Tragedy is not rare. We diagnose a child with a life-changing brain tumor; a mother suffers a brain aneurysm rupture, stealing her wit; a husband’s cancer metastasizes to his spinal cord, strangling his strength and independence. Death and disability precede me. Triumph is common, and I’ve reflected on it. There are many saves. We open the skull or the spine, pressure is relieved, and life or livelihood is restored. Most of our patients get better, rehabilitate, and move on.

I knew what neurosurgery was when I chose it. I’m not surprised. I would choose this life again every time. But by its nature, my work does give one a privileged exposure to the human condition, and in the moments between moments, you sometimes dwell on it.

The definition of human must be one who suffers. The mayfly suffers less. It emerges from its larval state and dies all in a one-day cycle, in a mad dash to reproduce and perhaps catch a glimpse of the sky. These ephemera, short-lived fliers as the ancient Greeks called them, repay their genetic debt, then retire forever. You quickly become impervious to suffering.

A page.

A man in a coma. He is on blood thinners for his cardiac arrhythmia and has a history of poorly controlled hypertension. Imaging reveals the price: he has suffered a grievous hemorrhage in his left thalamus and midbrain. He can no longer converse or comprehend, and his right body is paralyzed. He’ll never be the same.

“How old is he?” one of us asks.

“Eighty-one,” the other answers.

A head nod.

Somehow we might feel less badly if it occurs at an advanced age. We silently rationalize misfortune or try to. I can see the same thought travel through different minds: he was near the end of life. Ageism doesn’t make it less painful for him or his family. It mollifies us. We want suffering to make sense or at least lead to inevitable closure.

As I reflect, I consider what my undaunted colleagues would think of this introspection. In medicine, we have all pondered our personal predicament at some point or the other, regardless of our outward resolve. We’re surrounded by more signal and less noise. Every patient’s worst moment is our everyday. One has to wonder. We press forward. Tragedy in neurosurgery, and in medicine, differs by temporality. A trauma is instantaneous. Family and loved ones have little time to accept the reality. A brain tumor can be the beginning of a slow demise. There can be initial triumph, but many tumors are obstinate. A new normal settles in.

The frailty of human life is evident, perhaps too much so. Human life itself is improbable, and can seem insignificant. We live on “a mote of dust suspended in a sunbeam,” Carl Sagan aptly described in his book Pale Blue Dot. Somehow, in the vast nothingness, on a remote rock, we scrape out a life. We have desires, jobs, loves, children, conflicts, adventures, and failures. We write poetry, cure disease, climb mountains, and hurt each other. The cost of this improbability
is entropy and decay. Free radicals, friction, and fibrosis always win.

Another page.

A middle-aged, Portuguese-speaking patient was in a high-speed rollover on the interstate. His wife and child were passengers. The trauma team consulted me for his cervical spine fracture.

As I entered his room in the resuscitation unit, I found him on the phone. He had just learned his family didn’t make it. With one turn, what mattered most was lost. There was agony in his voice. I gave him space. More entropy, more pain. His strength and sensation were intact. He didn’t need surgery. With time, his bones would heal.

Another page.

A woman was transferred to the neurological intensive care unit from a local hospital. She was experiencing headaches for the past month, eventually earning her a CT of the head, and then a contrast-enhanced MRI of the brain. She was otherwise intact, without any change in her vision, strength, sensation, cognition, or language. It could be any other day in her life.

As I reviewed her imaging, it was clear this life was forever affected. Her corpus callosum—the bundle of 200 million nerve fibers that allow the left and right brain to communicate—was invaded by a foreign mass, an irregular, space-occupying lesion, causing adjacent swelling.

Where it occupied, the brain’s natural barriers had fallen, allowing, among other things, gadolinium contrast to enter. It was most likely glioblastoma, and could not be fully removed with surgery without causing significant, lasting damage. Though unlikely, it could be an infection or inflammatory disease, if she were fortunate. I discussed this with my attending. At the least she needed a biopsy. I spent time with her, collected her understanding, then reviewed with her what we knew, what we didn’t, and the further workup we needed.

Rarely genetic, possibly environmental, but mostly unknown factors allow glioblastoma, a malignant tumor of the brain that is often fatal, to maraud our most personifying faculties.

A cruel insult to our humanity.

Another page.

A young woman in the emergency room had been enduring piercing pain from her back to the bottom of her left foot. An MRI of her low back revealed the cause. The disc between her fifth lumbar vertebra and first sacral vertebra, at the base of her spine, had slipped backward, irritating a nerve root, inciting pain. She had tried exercise, physical therapy, pain management, and steroid injections with no relief. The pain was winning. I admitted her. Later my team would discuss options with her. She elected surgery. They took her to the operating room, drilled through a little bone, and removed the offending disc, letting her nerve breathe. She would leave the hospital the next day, back to normal, back to her life. She likely would not need us again.

When I walk from one corner of my hospital to the other, from one consult to the next emergency, I often listen to music. On this walk, Hans Zimmer’s peerless score for Christopher Nolan’s masterpiece Interstellar met my thoughts. In this future, humanity is forsaken, the Earth has become arid and uninhabitable, and we must leave. A cadre of scientists and astronauts resolves to save the human race by transporting embryos to a distant planet to establish a new colony. By the reliable hand of hubris, an airlock on the ship carrying the embryos explodes, and the ship’s precious remnants are in free fall. The last hope for our species to endure is spiraling in outer space to a dull end, to the sound of a ticking clock.

Even in health, so vulnerable are we. Yet, in these final moments, a lone astronaut, in a show of valiance and virtue, narrowly rescues the ship and saves this desperate effort to last.

My patients remind me, lest I forget, the human spirit is persistent.

The sun is starting to rise. The Earth rotates at 1,000 miles per hour, and the work of Rev. Thomas Bayes encourages us that the dawn will come. New light painting the walls and hallways shifts your perspective, even if temporarily. Signs of human activity again become apparent. The mayfly has its own predicament. It may suffer less, but it never feels a second sunrise. Though we are diurnal creatures, much of the human narrative unfolds in the twilight hours. I give the oncoming resident sign-out as such.

On my walk to the parking garage, I can hear the chickadees and finches chirping. I can smell spring. From somewhere, energy is invested in this improbable place, in us, for a time, a taunt to the Second Law. Do not go gentle.

It’s a zero-sum game, and the game is timed.

I’ll be back tonight.

This article originally appeared on  Magazine