The Challenges of Medical Care When Insurance Algorithms Rule – Walter Bradley Center for Natural and Artificial Intelligence

In the first portion of Episode 187, Good and bad algorithms in the practice of medicine (May 19, 2022), Walter Bradley Center director Robert J. Marks and anesthetist Dr. Richard Hurley discussed where algorithms help in medicine and where they dont. In this portion, they turn to how to get good medical care when you are dealing with an insurance company as well as medical staff and institutions. The two types of institution are, as we will see, very different.

Before we get started: Robert J. Marks, a Distinguished Professor of Computer and Electrical Engineering, Engineering at Baylor University, has a new book, coming out Non-Computable You (June, 2022), on the need for realism in another area as well the capabilities of artificial intelligence. Stay tuned.

This portion begins at roughly 7:31 min. A partial transcript and notes, Show Notes, and Additional Resources follow.

Dr. Hurley talks about battling algorithms while trying to provide spinal surgery for patients with back pain:

Richard Hurley: Theyve had all kinds of conservative care. Ultimately, I may decide to do a procedure called median branch blocks or facet nerve injections, where we anesthetize the joint to see if function and pain improves. Now, once I request that, I have to send all of my notes, all of my imaging, everything, to the insurance company. And we might hear back from them in a week. So when a patient comes in and they expect care at that particular time, I cant even offer it to them because it has to be approved.

And they [the insurance company] ask 15 different questions that my nurse will fill out electronically. But if she misses one just one or if she doesnt dot the Is and cross the Ts, then it gets denied. And the insurance companies have people who are not experts. Theyre not nurses. Theyre not even medical assistants. They are people who have been trained to read notes and then look for reasons to deny it.

Robert J. Marks: Well, this is the whole point, right? Theyre following fixed rigid algorithms which do not allow the flexibility that you need.

Richard Hurley: Right. And the companies that do this have just blossomed with managed Medicare. Everybody thinks managed Medicare is like standard Medicare. Thats false. You have standard Medicare but then you have to pay for your supplement, which is 20% of the care. Sometimes that costs more than the standard Medicare. Managed Medicare gets rid of all that. Its just one fee. So if an insurance company like Blue Cross, Blue Shield, or Aetna is involved, they can make money if they deny services or postpone them.

(Dr. Hurley explained that when insurance companies turn down payment for procedures, he is allowed to appeal and, in his case, 100% of them are approved over time. So it is a waiting game.]

Robert J. Marks: So theyre reasonable but you really have to go to battle with them. How much time do you spend battling the insurance companies?

Richard Hurley: Not all insurance companies require prior authorizations but all managed Medicare does. And almost all primary insurance does but standard Medicare does not. So if you have standard Medicare with a supplement, theres no pre-authorization People who sign up for managed Medicare are not aware that theyre going to be plagued with pre-authorizations.

Robert J. Marks: The funny thing is, I go in for procedures every once in a while and Im given an estimate of what the insurance company will pay. Invariably, almost 100% [of the time] I get a bill for extra money. In other words, the medical doctor doesnt know how much the insurance company will pay. They guess or maybe they have a standard reimbursement that they quote me but it never seems to be enough.

On one occasion I did get a check back that I paid too much, but that was a rarity. And that seems to me to be frustrating and a very bad algorithm, if you cant decide beforehand, what a procedures going to cost.

Richard Hurley: Absolutely, and you dont see that. In medicine, if there was no insurance and everybody paid cash, youd have the prices written outside on a billboard.

Robert J. Marks: So the insurance companies algorithms are, let me use the word, brittle. You cant crack them. You cant go outside of them. And that certainly must be frustrating. On the other hand, we know that we need algorithms because there needs to be some sort of constraint in terms of containing cost. So Richard, how could it be fixed?

Richard Hurley: The state of Texas came up with, in the last legislative session, the Golden Rule. Essentially, if a physician had six months of care in which virtually 90% of the requested authorizations were passed, then they would get a gold card. For the next six months, they can go ahead and schedule the procedure without getting authorization. It was supposed to have happened by, I think, the beginning of the year. But, interestingly enough, insurance companies have been trying to tack on different rules

Robert J. Marks: Now, when you or your assistant or your nurse talks to the insurance companies, I guess one of the things that must be frustrating to you is that you, as a physician, are arguing with somebody who is trying to follow a strict algorithm, but has no medical experience.

Richard Hurley: Correct.

Robert J. Marks: Yet you say that most of your controversies are concluded in a happy way. So how do they get around the algorithms? Are you given exemptions from the algorithm or what?

Richard Hurley: Well, hopefully thats going to happen. In other words, maybe one day Ill have a gold card. I dont know.

I doubt that [will happen for] interventional pain physicians, because the problem with chronic pain is that everybodys going to be a patient at some time or another. You will be. I will be Everybody copes with it differently. But authorizations for certain medications, like CGRP inhibitors for migraine, cost $600 a month. And if you think about how many millions of patients have that, and you just dump that on the system, insurers would really struggle. And I understand that as well

But the biggest problem I have is when I do a pre-authorization and it gets rejected, I go to appeal and go back and review my notes. And then I talk to the doctor there [at the appeal board]. The reason I win is because they didnt read all the notes. They didnt look at the MRI report.

They just missed it. And so I always ask them, Why do you ask for us to send all the notes on the patient when you dont read them? I mean, it doesnt make any sense.

Robert J. Marks: Oh, my gosh. The gold card, the more I think about it, the better idea it is. I like the idea of vetting physicians to give them more flexibility in what they do.

Another question I have, what is the difference between the different insurance companies? They all have these brittle sort of algorithmic criteria that they impose on the practice of medicine. Are there some which are better than other ones?

Richard Hurley: Im not the expert in that, so I cant tell you. We have less problems if people can afford standard Medicare with a supplement. When they get to Medicare age, I just encourage them to go that route. Even though youre healthy, and even though you may not have used a lot of healthcare, you dont know what the futures going to bring. Even though you may be paying more, thats the way I would go. Managed healthcare changes. What I mean by that is, Blue Cross/Blue Shield may have this criterion to do median branch blocks on a patient this year but next year theyre going to change it.

Robert J. Marks: Really? So the rules keep changing?

Richard Hurley: Oh, the rules change on the first of the year. They publish it. You might get to see it; you might not. And then all of a sudden you havent met that criterion, so it gets denied.

Robert J. Marks: How do you play the game without knowing the rules?

Richard Hurley: Well yeah, its really funny. You get denials, and then all of a sudden, you find out what the new rule is. Then you start adjusting your notes so that it fits their criteria. Those are kinds of things that we, as physicians, get really frustrated with. And those rules seem to be quite arbitrary. And theyre based on what they perceive as abuse, where all of a sudden this procedures going way up. And is there any reason for it? There may not be, and it may be abuse. But theyre penalizing all the other patients involved by changing the rules and not letting us know.

Robert J. Marks: A number of different companies give health insurance. Is there a monopoly, happening unsaid, where the rules for all of these insurance companies are roughly the same? The reason I ask this is, it seems that if there were true competition in the spirit of free enterprise, in the spirit of capitalism, between the different healthcare insurance providers, there would be a competition to give the best service. Which would be a motivation to sharpen their algorithms to make them more user-friendly to the physician.

Richard Hurley: I feel sorry for the lay person who doesnt know a lot about medicine and how healthcare is done. Because you basically would think, Well, Im probably not going to buy the cheapest, but Im certainly not going to buy the most expensive. And so Im going to try to hit one in the middle of the road.

If you ask a lay person in the United States what a pre-authorization for healthcare is, many patients might know, but most people dont. And they dont ask that when they go to get their plan. But in answer to your question, all the managed care providers use other companies to develop these algorithms to decide whether a procedure is medically necessary or if its experimental.

Robert J. Marks: Really? So they farm it out then.

Richard Hurley: Right. And one of the largest companies is a company called eviCore. They manage 100 million Medicare Advantage patients. 100 million.

Richard Hurley: So I usually have to talk to eviCore. By the way, I have the right under the state of Texas, to talk to a peer. In other words, if my nurse sets up an appeal, shell say, Now, Dr. Hurley does want a pain physician, board certified, who hell talk to. And by law, they have to get that In other words, I dont have to argue in front of an oncologist or a primary care [physician].

Robert J. Marks: Its peer review, if you will?

Richard Hurley: Right. Its a peer review. If that ever changes, its time for me to retire.

Robert J. Marks: Okay. You mentioned previously, and I thought this was interesting, if we didnt have insurance, the price of every procedure of every medicine would be printed on a billboard Do you think that this price is going to be higher or lower if we didnt have insurance?

Richard Hurley: Anytime the federal government gets into anything, the price goes up. You know that as well as I do the price goes through the roof. And thats because youre very inefficient if you run anything from Washington DC, as opposed to doing something local. The state can do things cheaper than the federal government can do. And the local governments can do things cheaper than that. Or a private institution, like Baylor or whatever

Robert J. Marks: Im wondering if some of these different insurances were localized more and separated, like the divestiture of the Bell Systems Labs, where they broke up the company, that maybe we would get a better deal?

Richard Hurley: Well, the drugs that we use in the United States cost X dollars. The same drug in Canada cost 75% less because they have one payer and thats the Canadian healthcare system. They buy all the drugs and they dispense them.

Robert J. Marks: Okay, so thats a vote for socialism.

Richard Hurley: It is, and Im not saying But what Im saying is, is there any reason why two years ago the price of insulin doubled and tripled and quadrupled? I mean, I dont know. I dont know that information. But then if the federal government goes in and says, Okay, you can sell insulin, but you can only sell it for $35 a vial how many people are going to play with that? I dont know. I dont have the answers in terms of the cost and how to control it.

All I know is everybody wants American healthcare and they come here in droves to get it. Its still the best. And I think it always will be as long as we do it. And its not truly private. Theres a mixture of the federal government, state government, private enterprise and all that other stuff.

But algorithms in healthcare to help patients get better, whether in surgery or on the floor, are designed by physicians to help other physicians or providers to do things. And the algorithms for insurance companies are done differently.

Robert J. Marks: So thats another interesting question. This eviCore, do you know to what degree they employ physicians to set up these policies?

Richard Hurley: I have no idea, but they must have hundreds, if not thousands of physicians that work either part-time. But please dont give me that job. I dont want to have to answer the phone and listen to appeals. I couldnt do that job.

Robert J. Marks: The interesting thing is probably all those medical doctors make these recommendations and its eventually decided by a bunch of guys with MBAs.

Richard Hurley: It may be true.

Robert J. Marks: Yeah, that would be my hunch. Okay. Any final words, Richard?

Richard Hurley: No, Im glad we had a chance to at least talk about this. I doubt that the public is aware of the algorithms that are involved in pre-authorization of patients for procedures or medications.

Frequently they blame the physician. Okay. Why are you not getting this done? Why am I having to wait? They dont realize that the hangup is not at the office where you see your physician. But its in computers and insurance companies that actually want a say in whether you can have that care or not.

My suggestion for people who are buying health insurance is: How much pre-authorization is this product going to have? And I might run away from it.

Always ask What, is the procedure? Do I have to have pre-authorization to be admitted to the hospital? Do I have to have pre-authorization for this type of surgery? All of those things.

Here is the first portion of this episode, with partial transcript, links, and notes:

Algorithms in medicine: Where they help and where they dont Removing creativity, nuance, and insight from medicine may result in cheaper care but not better care. Surgery robots help many surgeons today but, as anesthetist Richard Hurley explains to Robert Marks, insurance algorithms on who gets care can flop badly.

You may also wish to read Dr. Hurleys thoughts about addiction:

Opioids: The high is brief, the death toll is ghastly. Fentanyl has medical uses in, say, open heart operations where the patient is on life support; otherwise, it is a one-way ticket off the planet. Anesthesiologist Richard Hurley tells Robert J. Marks how Fentanyl affects the brain and why the street version is so deadly.

and

What anti-opioid strategies could really lower the death toll? Anesthetist Dr. Richard Hurley discussed with Robert J. Marks the value of cognitive behavior therapy reframing the problem. Life expectancy in the United States is decreasing due to opioid deaths, though the problem is now primarily street drugs, not medically prescribed ones.

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The Challenges of Medical Care When Insurance Algorithms Rule - Walter Bradley Center for Natural and Artificial Intelligence