If a picture is worth a thousand words, a video, if done well, can be worth thousands more.
Regular readers of HEALTH CARE un-covered know we have published lots of words about the barriers health insurance companies have erected that make it harder and harder for patients to get the care their doctors know they need.
It’s a perfect example of how something that was designed to protect patients from inappropriate and unnecessary care has been weaponized by health insurers to pad their bottom lines.
Prior authorization in today’s world all too often serves as a bureaucratic barrier, requiring patients and their doctors to obtain approval in advance from insurers before certain treatments, medications, or procedures will be covered.
While insurance companies argue that prior authorization helps control costs and ensure appropriate care, the reality is far grimmer.
Both patients and their health care providers suffer the consequences. Patients frequently face delays in receiving necessary treatments or medications, exacerbating their health conditions and causing unnecessary stress and anxiety. Many forgo needed care altogether due to the complexities and frustrations of navigating the prior authorization process. This practice not only undermines patients’ trust in their health care providers but also compromises their health, often leading to worsened conditions and, tragically, sometimes irreversible harm.
The burden of prior authorization falls heavily on clinicians and their office staff who must spend valuable time and resources navigating the bureaucratic red tape imposed by insurers. This administrative burden not only detracts from patient care but also contributes to physician burnout, dissatisfaction and moral crisis, according to many doctors.
Ultimately, the health insurance industry’s prioritization of profit over patient well-being is evident in its insistence on maintaining these barriers to care, perpetuating a system that defaults to financial gain at the expense of human lives.
The New York Times video cuts to the chase. Prior authorization, as practiced today by insurance companies, is “medical injustice disguised as paperwork.”
Day one of the healthcare strategy course I teach in the Stanford Graduate School of Business begins with this question: “Who here receives excellent medical care?”
Most of the students raise their hands confidently. I look around the room at some of the most brilliant young minds in business, finance and investing—all of them accustomed to making quick yet informed decisions. They can calculate billion-dollar deals to the second decimal point in their heads. They pride themselves on being data driven and discerning.
Then I ask, “How do you know you receive excellent care?”
The hands slowly come down and room falls silent. In that moment, it’s clear these future business leaders have reached a conclusion without a shred of reliable data or evidence.
Not one of them knows how often their doctors make diagnostic or technical errors. They can’t say whether their health system’s rate of infection or medical error is high, average or low.
What’s happening is that they’re conflating service with clinical quality. They assume a doctor’s bedside manner correlates with excellent outcomes.
These often false assumptions are part of a multi-millennia-long relationship wherein patients are reluctant to ask doctors uncomfortable but important questions: “How many times have you performed this procedure over the past year and how many patients experienced complications?” “What’s the worst outcome a patient of yours had during and after surgery?”
The answers are objective predictors of clinical excellence. Without them, patients are likely to become a victim of the halo effect—a cognitive bias where positive traits in one area (like friendliness) are assumed to carry over to another (medical expertise).
This is just one example of the many subconscious biases that distort our perceptions and decision-making.
From the waiting room to the operating table, these biases impact both patients and healthcare professionals with negative consequences. Acknowledging these biases isn’t just an academic exercise. It’s a crucial step toward improving healthcare outcomes.
Here are four more cognitive errors that cause harm in healthcare today, along with my thoughts on what can be done to mitigate their effects:
Availability bias
You’ve probably heard of the “hot hand” in Vegas—a lucky streak at the craps table that draws big cheers from onlookers. But luck is an illusion, a product of our natural tendency to see patterns where none exist. Nothing about the dice changes based on the last throw or the individual shaking them.
This mental error, first described as “availability bias” by psychologists Amos Tversky and Daniel Kahneman, was part of groundbreaking research in the 1970s and ‘80s in the field of behavioral economics and cognitive psychology. The duo challenged the prevailing assumption that humans make rational choices.
Availability bias, despite being identified nearly 50 years ago, still plagues human decision making today, even in what should be the most scientific of places: the doctor’s office.
Physicians frequently recommend a treatment plan based on the last patient they saw, rather than considering the overall probability that it will work. If a medication has a 10% complication rate, it means that 1 in 10 people will experience an adverse event. Yet, if a doctor’s most recent patient had a negative reaction, the physician is less likely to prescribe that medication to the next patient, even when it is the best option, statistically.
Confirmation bias
Have you ever had a “gut feeling” and stuck with it, even when confronted with evidence it was wrong? That’s confirmation bias. It skews our perceptions and interpretations, leading us to embrace information that aligns with our initial beliefs—and causing us to discount all indications to the contrary.
This tendency is heightened in a medical system where physicians face intense time pressures. Studies indicate that doctors, on average, interrupt patients within the first 11 seconds of being asked “What brings you here today?” With scant information to go on, doctors quickly form a hypothesis, using additional questions, diagnostic testing and medical-record information to support their first impression.
Doctors are well trained, and their assumptions prove more accurate than incorrect overall. Nevertheless, hasty decisions can be dangerous. Each year in the United States, an estimated 371,000 patients die from misdiagnoses.
Patients aren’t immune to confirmation bias, either. People with a serious medical problem commonly seek a benign explanation and find evidence to justify it. When this happens, heart attacks are dismissed as indigestion, leading to delays in diagnosis and treatment.
Framing effect
In 1981, Tversky and Kahneman asked subjects to help the nation prepare for a hypothetical viral outbreak. They explained that if the disease was left untreated, it would kill 600 people. Participants in one group were told that an available treatment, although risky, would save 200 lives. The other group was told that, despite the treatment, 400 people would die. Although both descriptions lead to the same outcome—200 people surviving and 400 dying—the first group favored the treatment, whereas the second group largely opposed it.
The study illustrates how differently people can react to identical scenarios based on how the information is framed. Researchers have discovered that the human mind magnifies and experiences loss far more powerfully than positive gains. So, patients will consent to a chemotherapy regiment that has a 20% chance of cure but decline the same treatment when told it has 80% likelihood of failure.
Self-serving bias
The best parts about being a doctor are saving and improving lives. But there are other perks, as well.
Pharmaceutical and medical-device companies aggressively reward physicians who prescribe and recommend their products. Whether it’s a sponsored dinner at a Michelin restaurant or even a pizza delivered to the office staff, the intention of the reward is always the same: to sway the decisions of doctors.
And yet, physicians swear that no meal or gift will influence their prescribing habits. And they believe it because of “self-serving bias.”
In the end, it’s patients who pay the price. Rather than receiving a generic prescription for a fraction of the cost, patients end up paying more for a brand-name drug because their doctor—at a subconscious level—doesn’t want to lose out on the perks.
Thanks to the “Sunshine Act,” patients can check sites like ProPublica’s Dollars for Docs to find out whether their healthcare professional is receiving drug- or device-company money (and how much).
Reducing subconscious bias
These cognitive biases may not be the reason U.S. life expectancy has stagnated for the past 20 years, but they stand in the way of positive change. And they contribute to the medical errors that harm patients.
A study published this month in JAMA Internal Medicine found that 1 in 4 hospital patients who either died or were transferred to the ICU had been affected by a diagnostic mistake. Knowing this, you might think cognitive biases would be a leading subject at annual medical conferences and a topic of grave concern among healthcare professionals. You’d be wrong. Inside the culture of medicine, these failures are commonly ignored.
The recent story of an economics professor offers one possible solution. Upon experiencing abdominal pain, he went to a highly respected university hospital. After laboratory testing and observation, his attending doctor concluded the problem wasn’t serious—a gallstone at worst. He told the patient to go home and return for outpatient workup.
The professor wasn’t convinced. Fearing that the medical problem was severe, the professor logged onto ChatGPT (a generative AI technology) and entered his symptoms. The application concluded that there was a 40% chance of a ruptured appendix. The doctor reluctantly ordered an MRI, which confirmed ChatGPT’s diagnosis.
Future generations of generative AI, pretrained with data from people’s electronic health records and fed with information about cognitive biases, will be able to spot these types of errors when they occur.
Deviation from standard practice will result in alerts, bringing cognitive errors to consciousness, thus reducing the likelihood of misdiagnosis and medical error. Rather than resisting this kind of objective second opinion, I hope clinicians will embrace it. The opportunity to prevent harm would constitute a major advance in medical care.
Private equity firm Apollo Global Management’s ownership of two large health systems — Louisville, Ky.-based ScionHealth and Brentwood, Tenn.-based Lifepoint Health — downgrades hospital services, hurts workers and puts patients at risk, according to a study published Jan. 11 by the Private Equity Stakeholder Project.
Since acquiring Lifepoint in 2018 and spinning off ScionHealth in 2021, Apollo has consolidated ownership of 220 hospitals in 36 states, with a workforce of about 75,000 employees. Many of the hospitals have experienced service cuts, layoffs, poor quality ratings and regulatory investigations, according to the report.
The report comes amid rising scrutiny of private equity hospital ownership.
In December, the Senate Budget Committee launched an investigation into the effects of private equity ownership on hospitals that specifically mentioned Apollo’s ownership of Lifepoint. Iowa Sen. Chuck Grassley and Rhode Island Sen. Sheldon Whitehouse requested “documents and detailed answers” about certain hospital transactions and the degree to which private equity firms are calling the shots at hospitals.
A Harvard Medical School-led study published Dec. 26 in JAMA also found that hospitals that are bought by private equity-backed companies are less safe for patients. On average, patients at private equity-purchased facilities had 25.4% more hospital-acquired conditions, according to the study.
“Apollo’s purchase of these hospital systems follows a disturbing pattern of harm caused by the growing influence of private equity in the healthcare sector,” PESP Healthcare Director Eileen O’Orady, said in a news release. “Private equity’s utmost priority to maximize short-term profit over the long-term viability of the companies it controls leads to excessive debt, cost cutting, worse outcomes for patients and deteriorating working conditions for employees. Apollo’s management of its hospitals seems to follow the usual playbook.”
The study, “Apollo’s Stranglehold on Hospitals Harms Patients and Healthcare Workers,” was developed in conjunction with the American Federation of Teachers and the International Association of Machinists and Aerospace Workers. Clickhere to access the full report.
Apollo, Lifepoint and ScionHealth did not respond to Becker’s request for comment.
This week, Statpublished a scathing investigation into the way UnitedHealth Group subsidiary NaviHealth uses an algorithm, nH Predict, to deny Medicare Advantage (MA) patients access to rehabilitation services and long-term care. United set a target to keep rehab stays within one percent of nH Predict’s projection for the year.
Interviews with former case managers and access to internal documents reveal that NaviHealth employees faced disciplinary action and even termination if they approved care that strayed from these algorithmic recommendations.
UnitedHealthcare, the nation’s largest insurer, is now subject to a class-action lawsuit filed this week over these practices. But NaviHealth’s impact extends beyond just United beneficiaries, as other insurers, covering around 15M MA enrollees, also use its services.
The Gist:This article provides a stark example of what can happen when an artificial intelligence (AI) algorithm is used not to complement, but to replace, clinical judgment.
While profit incentives in US healthcare are nothing new, what’s pernicious about an algorithm like nH Predict is how it replaces individual patients, whose needs vary, with a theoretical “average patient”, whose health and life needs can be easily predicted by the handful of data points available to the insurer.
When patients fail to recover along expected timelines—that are imperfectly calculated by incomplete datasets—they’re the ones who suffer.
U.S. hospitals performed more than 100,000 surgeries on older patients during the first year of the pandemic, according to a new Lown Institute analysis.
The healthcare think tank relied on Medicare claims data and analyzed eight common low-value procedures. It called the 100,000 procedures unnecessary and potentially harmful in a press release. It found that between March and December 2020, among the most-performed surgeries were coronary stents and back surgeries.
The procedures either offered little to no clinical benefit, according to the institute, or were more likely to harm patients than help them.
“You couldn’t go into your local coffee shop, but hospitals brought people in for all kinds of unnecessary procedures,” Vikas Saini, M.D., president of the Lown Institute, said in a statement. “The fact that a pandemic barely slowed things down shows just how deeply entrenched overuse is in American healthcare.”
Here is the volume of each procedure analyzed, for a total of 106,474 procedures identified:
1. Stents for stable coronary disease: 45,176 2. Vertebroplasty for osteoporosis: 16,553 3. Hysterectomy for benign disease: 14,455 4. Spinal fusion for back pain: 13,541 5. Inferior vena cava filter: 9,595 6. Carotid endarterectomy: 3,667 7. Renal stent: 1,891 8. Knee arthroscopy: 1,596
Among the “U.S. News & World Report” 20 top-ranked hospitals, all had rates of coronary stent procedures above the national average in what the Lown Institute called “overuse.” Four had at least double the national average, including the Cleveland Clinic, Houston Methodist Hospital, Mt. Sinai and Barnes Jewish Hospital. The procedures and overuse criteria were based on previous Lown research.
“We’ve known for over a decade that we shouldn’t be putting so many stents into patients with stable coronary disease, but we do it anyway,” Saini said. “As a cardiologist, it’s frustrating to see this behavior continue at such high levels, especially during the pandemic.”
In response to the Lown analysis, the American Hospital Association said in a statement Tuesday that delays or cancelations in non-emergency care may have negative outcomes on patients. “Lown may define these services as ‘low value,‘ but they can be of tremendous value to the patients who receive them,” the statement read.
It also pointed to its response to last year’s Lown analysis, which it criticized as being based “on data that are not only incomplete, but also not current.” The organization argued the services surveyed only represent a portion of the care hospitals provide. It added that procedures are determined by physicians based on an evaluation of the patient’s medical needs.
It’s “a trickle that will become a torrent,” Ashish Jha, dean at Brown University’s School of Public Health, tweeted.
More hospitals are likely to require employees receive a COVID-19 vaccine, experts said, to further protect the sick and vulnerable patients who rely on them for care.
A Houston-area hospital captured headlines after taking a firm stance on requiring vaccines that prevent severe illness of the coronavirus, which has killed more than 600,000 in the U.S. and ravaged the economy.
Houston Methodist employees who refused the vaccine were either terminated or resigned. A judge earlier this month sided with the hospital and tossed out an employee lawsuit that was seeking to block the mandated inoculation. The ruling may give other hospitals the green light to require the jab, and as more facilities put a similar policy in place, others are likely to follow, experts said.
It’s “a trickle that will become a torrent,” Ashish Jha, professor and dean at Brown University’s School of Public Health, posted Thursday on Twitter.
3 large health systems in Massachusetts to require all workers to be vaccinated.
Given the critical need to protect vulnerable patients, its critical all hospitals do this.
Some of the nation’s largest health systems have yet to mandate the shot, including Kaiser Permanente and CommonSpirit Health.
“Vaccination will only be required for Kaiser Permanente employees if a state or county where we operate mandates the vaccine for health care workers,” the company said in an email.
The American Hospital Association continues to hear that a growing number of its members are requiring the vaccine, with some exemptions. However, many member hospitals are waiting until the FDA grants full approval, a time when more safety and efficacy data will be made available.
“Getting vaccinated is especially critical for health care professionals because they work with patients with underlying health conditions whose immune systems may be compromised,”AHA, which has not taken on stance on the requirement, said in a statement.
The mandates raise ethical questions, some say, pointing to the profession’s promise to “do no harm.”
Arthur Caplan, head of medical ethics at New York University School of Medicine, said the codes of ethics that doctors and nurses says to put patients first, do no harm and protect the vulnerable.
“Of course they should be vaccinated,” he said. “If they don’t want to get vaccinated, I think they’re in the wrong profession.”
The Equal Employment Opportunity Commission said employment law does not prohibit employers from requiring the jab, essentially giving the green light to employers to put incentives and requirements in place for their workers. The EEOC is the federal agency tasked with ensuring that workplaces do not discriminate.
Some states are going against the tide and signing legislation that bars vaccine mandates, including Florida. The city of San Francisco will require hospital employees and workers in high-risk settings to get the vaccine. San Francisco, like other employers and universities, will require all city workers get inoculated.
The differing policy stances across the country creates additional hurdles for corporations with a large footprint.
Facing intense criticism from hospital executives and emergency physicians, the nation’s largest health insurer, UnitedHealthcare (UHC), delayed the implementation of a controversial policy aimed at reducing what it considers to be unnecessary use of emergency services by its enrollees.
The policy, which would have gone into effect next month, would have denied payment for visits to hospital emergency departments for reasons deemed to be “non-emergent” after retrospective review. Similar to a policy implemented by insurer Anthem several years ago, which led to litigation and Congressional scrutiny, the UHC measure would have exposed patients to potentially large financial obligations if they “incorrectly” visited a hospital ED.
Critics pointed to longstanding statutory protections intended to shield patients from this kind of financial gatekeeping: the so-called “prudent layperson standard” came into effect in the 1980s following the rise of managed care, and requires insurance companies to provide coverage for emergency services based on symptoms, not final diagnosis. UHC now says it will hold off on implementing the change until after the COVID-19 national health emergency has ended, and will use the time to educate consumers and providers about the policy.
Like many critics, we’re gobsmacked by the poor timing of United’s policy change—emergency visits are still down more than 20 percent from pre-pandemic levels, and concerns still abound that consumers are foregoing care for potentially life-threatening conditions because they’re worried about coronavirus exposure. Perhaps UHC is trying to “lock in” reduced ED utilization for the post-pandemic era, or perhaps they never intended to enforce the policy, hoping that the mere threat of financial liability might discourage consumers from visiting hospital emergency rooms.
While we share the view that consumers need better education about how and when to seek care, combined with more robust options for appropriate care, this kind of draconian policy on the part of UnitedHealthcare just underscores why many simply don’t trust profit-driven insurance companies to safeguard their health.
An Advocate Aurora Health pharmacist who intentionally damaged 570 doses of COVID-19 vaccine was sentenced to three years in prison, according to NBC affiliate WTMJ of Milwaukee.
Steven Brandenburg worked at Aurora Medical Center in Grafton, Wis., when he removed Moderna COVID-19 vaccine vials from refrigeration twice in December. He told investigators he believed the vaccine could harm patients or change their DNA.
He was arrested Dec. 31 on charges of first-degree recklessly endangering society, adulterating a prescription drug and criminal damage to property.
Fifty-seven people received the vaccines after they were left out, but they will likely experience no harm, according to officials with Aurora Health Care, based in both Milwaukee and Downers Grove, Ill.
After Aurora Health Care investigated the incident, Mr. Brandenburg was fired. He and the Wisconsin Pharmacy Examining Board agreed on his license suspension during a Jan. 13 meeting.
Mr. Brandenburg on Jan. 26 agreed to plead guilty to two counts of attempting to tamper with consumer products with reckless disregard.
On June 8, Mr. Brandenburg was sentenced to three years in prison. After serving his sentence, he will face another three years of supervised release.
Mr. Brandenburg told the court he was “desperately sorry and ashamed” about tampering with the vaccines. He also said Aurora Health Care is a “pillar of the community” and “did not deserve” the incident, according to WTMJ.
A New York physician has been charged with manslaughter in the second degree and is facing other felonies related to the overdose death of a patient, New York Attorney General Letitia James announced Feb. 19.
Sudipt Deshmukh, MD, allegedly prescribed a lethal mix of opioids and other controlled substances that resulted in the overdose death of a patient. The physician allegedly knew the patient struggled with addiction.
An indictment, unsealed Feb. 18, alleges that between 2006 and 2016, Dr. Deshmukh ignored his professional responsibilities by prescribing combinations of opioid painkillers and other controlled substances, including hydrocodone, methadone and morphine, without regard to the risk of death associated with the combinations of those drugs.
Dr. Deshmukh is facing several felony charges, including healthcare fraud, for allegedly causing Medicare to pay for medically unnecessary prescriptions.
The indictment comes after the attorney general’s office filed a felony complaint against Dr. Deshmukh in August. In 2019, the New York State Office of Professional Medical Conduct found that he committed several counts of misconduct.
HENRY KOTULA 