if I approve too many expensive drugs, I won’t get my bonus at the end of the month.

Who Actually Is Reviewing All Those Preauthorization Requests?





Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting.

Don’t worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do.

However, the audience was a bit unusual for me.

Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care.

I guess that explains why they had time in the middle of the day for an hour-long presentation.

I gave my talk, but there were no questions.

I had a few moments afterwards to speak to my audience. Since the physicians were not involved in patient care, I wondered why they wanted to hear a talk about new advances in heart failure.

The response surprised me: “We no longer care for patients, but we care about what’s going on. You see,

most of us are employed by insurance companies to do preauthorization for drugs and medical procedures.”

My jaw dropped: “I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients?” The answer was yes.

I was really curious now. “So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities?”

Their answer hit me hard. “Oh, we’ve heard about those drugs before. We’re asked to approve their use for patients all the time. But we don’t approve most of the requests. Nearly all of them are outside of the guidelines that we are given.”

I stammered. “I just showed you evidence that these new drugs and devices make a real positive difference in people’s lives. People who get them feel better and live longer.”

The physicians agreed. “Yes, you were very convincing. But the drugs are too expensive.

So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again.”

I was astonished. “If the drugs will help people, how can you say no?”

 Then I got the answer I did not expect. “You see, if it weren’t for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn’t a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare.”

I responded quickly. “But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren’t getting the drugs that they need.”

One physician looked at me as if I were from a different planet.

“You really don’t understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare.”

Before I had a chance to respond, he continued:

“Plus, if I approve too many expensive drugs, I won’t get my bonus at the end of the month.

So giving out too many approvals wouldn’t be a smart thing for me to do. Would it?”

I walked out of the room slowly. Although I had been invited to share my knowledge, it turned out that — this time — I was the real student.

The physicians in the audience taught me a valuable lesson. And amazingly, none of them showed a single slide.

4 Responses

  1. My prior primary care provider died because of this situation. He was in very good health until he was diagnosed with stage 4 throat cancer, having never smoked a day in his life.
    His insurance company refused to approve a drug that could have saved him because it was too expensive. He died waiting on an appeal.
    He had spent all his personal money from working for the Indianapolis Colts taking care of their players. He opened a clinic to serve the low income patients of the community most on Medicaid and when they paid late, he used his own funds to keep it open so his patients wouldn’t suffer.
    He truly cared about people. Because of this, he had no money to help himself when he needed medicine.
    Something is very wrong in this country!

  2. UN Friggin real!!!!

  3. It’s a shame we have insurance and doctors playing God. My brother has stage 4 cancer. He is on medicare and has United health care. He needed a medicine for his cancer. The cost was $7000 a month. He was referred to MD Anderson for treatment. They wouldn’t even let him see a doctor till they approved him. They declined to treat him two times. They told my brother that they was trying to neg. a rate and couldn’t come to an agreement. United health care would only pat $3000 leaving a balance of $4000 a month for the meds. I guess it wasn’t enough money for them to treat my brother. We found the cancer center in the town we live in and said they would treat him. They spoke to the pharmaceutical company direct about the drug and they denied him 3 times saying the drug the cancer center was wanting wouldn’t help my brother. After the 4th appeal and all the paperwork, tax returns proven he didn’t have a way to pay for the drug the pharmaceutical company took United health cares $3000 and sent it to him direct. After 2 months with cancer the size bigger than a grapefruit attached to his bone he was able to get treatment. He did the radiation and took the cancer medicine (still taking it) I am thankful he is feeling a lot better and in less pain. The medicine is what he needed and it gives my brother a chance to live life longer and less painful. How do these doctors live with themselves playing God for a BONUS??? When judgement day comes and they stand in front of the real God they will have to answer…

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