The biggest scam in medicine begins Jan 1

We might have hoped that eventually, Congress would understand its mission: To defend and improve the lives of the people.

And we might have hoped that eventually, Congress would understand it has the unlimited ability to create the dollars to defend and improve the lives of the people.

And we might have hoped that we, the public, would learn that our federal taxes do not fund federal spending, so even “wasteful” federal spending costs us nothing, and in fact, benefits us by adding growth dollars to the economy.

Sadly, those hopes, once again, are dashed, as an intentionally ignorant and uncaring Congress and President have found a new way to make our lives worse.

In a six-year experiment that begins Jan. 1, millions of original Medicare beneficiaries in six states could be required to get advance approval, called prior authorization (PA), before certain medical services, procedures or devices are covered.

If successful, the pilot project could lead to wider use of prior authorization in original Medicare, possibly using artificial intelligence (AI). The practice is already widely used in Medicare Advantage, with some plans using AI and algorithmic software to help make coverage decisions.

It’s designed to speed up coverage decisions and cut wasteful spending on at least 16 devices, procedures and services that are “particularly vulnerable to fraud, waste and abuse or inappropriate use,” according to CMS.

There is no way that waiting for prior authorization can “speed up” anything.

Technology companies that participate will be paid based on savings from denied medical claims, which has drawn the ire of the American Medical Association and consumer organizations.

If your pay depends on your denying health care claims, what will you do?

Right. Deny claims. And that is exactly the experience people have had with PA.

The pilot project comes amid concerns from lawmakers, government watchdogs and others that Medicare Advantage plans’ prior authorization procedures can create burdens for caregivers, who have to figure out how to appeal, and risk the health of patients by delaying or denying care that would otherwise be covered under original Medicare.

Prior authorization helps save the federal government money by screwing sick people.

There is no simpler, more accurate way to say it. Under the false banner of cutting “waste,” the government plans to cut services. Remember, because the government is Monetarily Sovereign, “cutting waste” is meaningless.  

Unlike state and local governments, the federal government creates unlimited dollars by pressing computer keys. In reality, so-called “wasteful” federal spending benefits the economy. It adds to Gross Domestic Product.

GDP = Federal Spending + Nonfederal Spending + Net Exports

The sole purpose and effect of prior authorization is to reduce, delay, and eliminate medical services and to transfer much of the remaining cost to the ill.

It is a program only a right-wing Republican could love — and even that right-winger won’t love it when he/she has payment or procedure denied because some bureaucrat in Washington won’t pay for the procedure your doctor prescribed.

The terrible irony is that while the Republicans, under Trump, tell you that Washington is filled with “useless” people who must be fired randomly, the Republicans want those remaining “useless” people to make your healthcare decisions. 

Here are some examples of what the current administration wants to subject you to:

94% of physicians report care delays due to prior authorization, AMA says

The survey underscores the urgent need for reform and regulation of prior authorization, the AMA said.

In December 2022, the Centers for Medicare and Medicaid Services released a proposed rule to speed up prior authorization approval.

Physicians spend almost two business days each week on prior authorization requests and 35% have had to hire additional staff to exclusively handle the administrative burden, the AMA said.

The AMA said other survey results show that 80% of physicians report that prior authorization can lead to treatment abandonment; 33% of physicians report prior authorization leading to a serious adverse event for a patient in their care – with 9% reporting it’s led to permanent bodily damage, disability or death.

Prior authorization complexity does not eliminate unnecessary treatments, the AMA said. Eighty-six percent of physicians report that prior authorization leads to higher overall utilization of healthcare resources.

Many ophthalmologists have faced – and continue to face – broad prior authorization policies on cataract surgeries from certain insurance giants, the AMA said.

Rheumatologists have long decried prior authorization policies for worsening outcomes for their patients. Many rheumatology patients rely on expensive biologic medication to treat their disease, meaning they are commonly a target of insurers, the AMA said.

And then there’s this evaluation of the “Save the government money by costing people money, their health and their lives program.”

Imagine you have a cancer growing in you, and your doctor tells you that you need treatment right away. Good luck with that:

The Patient Experience of Prior Authorization for Cancer Care

Question What is the patient experience with prior authorization (PA) for cancer-related care?

Findings This cross-sectional study of 178 patients with cancer with experience with PA showed delays to care (with most delays ≥2 weeks), increased anxiety, and patient administrative burden. The PA process was rated bad or horrible by most respondents and was associated with decreased trust in the health care system.

This study suggests that PA for cancer care can have discrete negative associations with outcomes for patients; streamlining the process is key to optimizing the quality of care delivered and improving the patient experience with cancer care.

Prior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.

Results:
22% did not receive recommended care due to delays or denials.
69% reported a PA-related delay in care; of those with delayed care,
73% reported a delay of 2 or more weeks.
67% had to personally become involved in the PA process;
20% spent 11 or more hours dealing with PA issues.
The PA experience was rated as bad 40% or horrible 32%
PA-related anxiety was higher than usual anxietyand was correlated with delay length, and time spent
After PA, 89% of patients trusted their insurance company less, and83% trusted the health care system less.
22% of patients did not receive the care recommended by their treatment team because of PA.

PA processes may require clinicians and patients to navigate a complex approval pathway and can lead to delays in receipt of care or denials of recommended
Delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.

Oncologists have reported suboptimal care and delays in cancer treatment owing to PA’s bureaucratic interference in clinician-patient decision-making; an oncology survey found that payer pressures, including handling PA, ranked as the most pressing practice concern.

An American Medical Association survey found that 90% of respondents reported treatment delays due to PA.
73% of surveyed oncologists reported that patients “routinely” expressed concerns to them about PA-related delays.

About 33% of physicians in the AMA survey said PA criteria are rarely or never evidence based.
62% of physicians reported difficulty in determining whether a service required PA.
Patients described the process as arbitrary, with lack of communication, lack of transparency

Does this really sound like an improvement to Medicare? Does it sound like you will receive better care at less cost?

IN SUMMARY

1. Your federal taxes do not fund government spending. The sole purposes of federal taxes are to regulate the economy and to stabilize the dollar.
2. The federal government cannot run short of money. It creates dollars simply by voting.
3. FICA does not fund Medicare. The federal government has the power to fund a comprehensive, no-deductible Medicare plan for everyone of every age in America, without collecting a penny in taxes.
4. The current administration is in the process of firing hundreds of thousands of federal workers; yet, those remaining workers are expected to administer PA, a complex process that requires medical expertise and handling hundreds of thousands of individual cases. 
5. No one knows your medical needs better than your doctor, yet the government wants a Washington bureaucrat to make your medical decisions.
6. Delays or refusals to provide services have cost people’s health and lives.
7. PA does not save you or your doctor time or money. PA does not improve service. On the contrary, PA costs you and your doctor time and money, and worsens medical services.
8. Private insurance companies are dollar-constrained. They use PA so they can deny services. Their people are paid to deny services. The federal government is not dollar-constrained. Its purpose is to provide service.

In short, PA is an even worse idea than the notorious “debt ceiling,” and that is really saying something.

Rodger Malcolm Mitchell

Monetary Sovereignty

Twitter: @rodgermitchell

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MUCK RACK: https://muckrack.com/rodger-malcolm-mitchell;

https://www.academia.edu/

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A Government’s Sole Purpose is to Improve and Protect The People’s Lives.

MONETARY SOVEREIGNTY