Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Utilization management is medicine’s great conspiracy theory

Arthur Lazarus, MD, MBA
Physician
June 20, 2022
Share
Tweet
Share

So-called “evidence-based guidelines” are slowly destroying the practice of medicine, and companies that develop these proprietary guidelines are guilty of conspiring with payers to deny individuals necessary medical treatment.

Guideline developers, health plans, and their benefit managers contend that utilization management (UM) programs based on medically proven guidelines will reduce unwarranted clinical practice variation and improve care quality and cost. But real-world evidence paints an entirely different picture. A recent study conducted by the American Medical Association (AMA) found that:

  • 88% of physicians considered prior authorization a high or extremely high burden, devoting almost 2 business days (13 hours) per week to this activity, along with staff
  • 93% of physicians reported treatment delays due to prior authorization requirements, with 82% reporting treatment abandonment on some occasions, which means patients had to settle for no treatment or treatment other than what their physicians ordered
  • Approximately one-third of physicians reported their patients suffered a serious adverse event due to prior authorization – hospitalization, disability or a life-threatening event
  • 30% of physicians felt that utilization review criteria are rarely or never evidence-based, despite virtually all health plans asserting otherwise, and only 1% of physicians felt that prior authorization programs led to positive patient outcomes
  • More than half (51%) of physicians reported that prior authorization can impact a patient’s work performance, leaving the AMA to conclude: “[I]f PA-related care delays and treatment abandonment lead to negative clinical outcomes, patients may miss work or not be as productive – hurting employers’ bottom line in the long run.”

The AMA findings contrast sharply with claims made by payers and guideline developers. Improved quality and decreased costs are simply fallacies, a BIG lie perpetrated by guideline purists for years. The truth is health care costs and inflation continue to outpace consumer costs and inflation, and the United States health system ranks last overall among 11 high-income countries in terms of access to care, care process, administrative efficiency, equity, and health care outcomes.

The names of the conspirators are quite familiar to practicing physicians. Guideline developers include Milliman and InterQual. The top five payers are United, Anthem, Aetna, Cigna, and Humana. There are also a host of companies contracted by payers – co-conspirators – that conduct specialty reviews in diverse areas ranging from behavioral health to orthopedic and spinal surgery to oncology treatment – not to mention pharmacy benefit managers who have contributed to the crisis in drug pricing and affordability.

It’s difficult to turn a blind eye to the disastrous effect of utilization management (UM) on patients and employers. The AMA has proposed a series of reforms to streamline, standardize and simplify UM procedures, particularly for medically vulnerable elderly patients. But the AMA’s suggestions haven’t fixed anything yet, and doctors’ frustrations are mounting – even the president of the AMA has shared his personal angst in writing.

The Centers for Medicare and Medicaid Services (CMS) has declined to adopt a proprietary decision support tool like Milliman or InterQual, embracing instead a broader definition of medical necessity grounded in accepted standards of medicine. In my opinion, this is the direction we need to take, eschewing utilization management altogether and returning the practice of medicine to doctors, where it belongs.

Do we really need companies like Milliman and InterQual to dictate how medicine should be practiced? Didn’t we learn that in medical school and residency training? Don’t we stay updated through continuing medical education courses and maintenance of board certification?

We certainly don’t need health insurers and their hired guns pretending to know our patients better than us. They don’t walk in our shoes. And we definitely don’t need to equip lawyers with “evidence” to be used against us in malpractice cases, which is one of the unintended consequences of evidence-based guidelines, as is the retrospective down coding and denial of claims.

Doctors prefer to think independently and exercise their own judgment in caring for patients. We prefer the evidence to inform our diagnoses and treatment. Objective findings constitute only one of many factors that underlie the art of medical practice. Surely, practical reasoning and wisdom based partly on science but mainly on experience and judgment count as much, if not more, than cost-conscious treatment algorithms.

I can’t tell you how many times I’ve heard doctors say they don’t want utilization management companies meddling in their affairs. They dislike it when physician advisers – with passion, misdirected though it might be – second-guess their clinical decisions. Of course, there are outlier physicians whose practice does not conform to medical standards, and they need to be educated and, in rare instances, disciplined. But achieving cost-effective care doesn’t require an army of pseudoscientists infringing on our turf pretending to be clinical experts. It is time for the truth to ring out loud and clear – doctors are quite capable of thinking for themselves.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.

Image credit: Shutterstock.com

Prev

Why is there a formula shortage? 

June 20, 2022 Kevin 1
…
Next

Precision medicine: the rifle vs. shotgun approach to cancer treatment

June 20, 2022 Kevin 1
…

ADVERTISEMENT

Tagged as: Public Health & Policy

Post navigation

< Previous Post
Why is there a formula shortage? 
Next Post >
Precision medicine: the rifle vs. shotgun approach to cancer treatment

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Arthur Lazarus, MD, MBA

  • 5 years later: Doctors reveal the untold truths of COVID-19

    Arthur Lazarus, MD, MBA
  • How a $75 million jet brought down America’s boldest doctor

    Arthur Lazarus, MD, MBA
  • What independent bookstores and private practice doctors teach us about human connection

    Arthur Lazarus, MD, MBA

Related Posts

  • How social media can advance humanism in medicine

    Pooja Lakshmin, MD
  • Why academic medicine needs to value physician contributions to online platforms

    Ariela L. Marshall, MD
  • The difference between learning medicine and doing medicine

    Steven Zhang, MD
  • KevinMD at the Richmond Academy of Medicine

    Kevin Pho, MD
  • Medicine rewards self-sacrifice often at the cost of physician happiness

    Daniella Klebaner
  • A paradigm shift in acute pain assessment and management

    Myles Gart, MD

More in Physician

  • Why being a physician mom is harder than anyone admits

    Cynthia Chen-Joea, DO, MPH
  • Removing vaccine advisers could jeopardize lives

    J. Leonard Lichtenfeld, MD
  • Why would any physician believe that the practice of medicine will become less abusive for them in the future?

    Curtis G. Graham, MD
  • The hidden war on doctors: Understanding administrative violence

    Maryna Mammoliti, MD
  • How doctors can stop frivolous lawsuits before they start

    Howard Smith, MD
  • How the 10th Apple Effect is stealing your joy in medicine

    Neil Baum, MD
  • Most Popular

  • Past Week

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
  • Recent Posts

    • Essential questions about nurse practitioner liability insurance [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why being a physician mom is harder than anyone admits

      Cynthia Chen-Joea, DO, MPH | Physician
    • 9 domains that will define the future of medical education

      Harvey Castro, MD, MBA | Tech
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • What led me from nurse practitioner to medical school

      Sarah White, APRN | Education
    • Why local cardiac CT scans could save your life

      Benjamin Cohen, MD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
  • Recent Posts

    • Essential questions about nurse practitioner liability insurance [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why being a physician mom is harder than anyone admits

      Cynthia Chen-Joea, DO, MPH | Physician
    • 9 domains that will define the future of medical education

      Harvey Castro, MD, MBA | Tech
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • What led me from nurse practitioner to medical school

      Sarah White, APRN | Education
    • Why local cardiac CT scans could save your life

      Benjamin Cohen, MD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...