Episode 36: Reforming Prior Authorization Requirements in pain medicine w. Dr. Josh Suderman

Feb 17, 2020

This Episode

Interview w/ Dr. Josh Suderman

You Will Learn

 You will learn:
– What a prior auth is, why it exists, and the different stakeholders in the context of this discussion (physicians, patients, insurers, others).
– Dr. Suderman’s first experience(s) with a prior auth, and a few times when he saw how it detrimentally impacted patient care.
– The other important considerations to be aware of for physicians trying to streamline their practice to deal with prior auth burden, as well as to advocate for patient wellbeing and trying to constructively bring reform to healthcare.

Resources & Links

In this episode, Justin sits down with Dr. Josh Suderman. Josh is an anesthesiology & pain boarded physician at the Javery Pain Institute in grand rapids Michigan. In this episode, you will hear about his experience in treating pain in the context of a small pain group. They also tackle the topic of prior authorizations, what they are, why they happen, and his work to make prior authorizations less of a problem for both patients and doctors. 

Justin (00:20):
Thanks for listening this week I had a great conversation with Dr. Josh Suderman. We’ve talked about prior auths and the impact that they have in the pain management infrastructure for physicians, for patients, the delays that they cause, the reasons that they exist, and some of the work legislatively. This being done right now in the state of Michigan to be able to perform the trier off process to be able to make it less onerous for everyone involved. So as always, thanks for tuning in. Hello and welcome to episode 36 of the anesthesia success podcast. I’m very pleased to be joined today by dr Joshua Suderman. Josh is an anesthesiology and pain boarded physician at the Javery pain Institute in grand Rapids, Michigan. He’s joining me today to talk about his experience in treating pain in the context of a smaller pain practice. We’re also going to tackle the topic of prior authorizations, what they are, why they happen. And Josh has worked to make prior auths less of a problem for both patients and physicians. Josh, thanks for joining us today.
Dr. Suderman (01:20):
Hey, thanks for the opportunity. Really looking forward to it.
Justin (01:23):
So tell us a little bit about your current practice there in Michigan.
Dr. Suderman (01:26):
So in Michigan we’re a independent private pain management clinic. We have two physicians two nurse practitioners and a physician’s assistant. We have about 50 staff members. We do office based procedures, management occasions and coordinate multi-disciplinary plans, physical therapy, pain psychology.
Justin (01:45):
Got it. You said 55 zero staff members?
Dr. Suderman (01:48):
Yes, it’s a pain management is a very overhead, heavy specialty. We have to have a lot of staff to prepare patients for many surgeries, meaning their interventional procedures look after them after the procedure. So there’s a lot of overhead, but it gives the opportunity to make a lot of good relationships with staff. And you know, the patients, they meet, all of us and the physicians are important, but the whole staff helps to care for the patient. And we are close to family.
Justin (02:14):
Absolutely. So how long have you been practicing it at this in this current location?
Dr. Suderman (02:19):
So Javery pain Institute. I’ve been here a little over five years. August of 2014 when I started.
Justin (02:25):
And that was your first job out of fellowship?
Dr. Suderman (02:28):
Yeah. Yeah, it was I, I remember hearing a dr deer on one of your recent episodes. He said, you know, I’ve only had one job and that’s kinda unique for any career. I sure hope to keep it that way. Has been my first job. I was at payments and fellow at the university of Michigan. Prior to that it was an anesthesia resident there. I did my medical school in Virginia and actually before medical school I was an orderly in a hospital. I was an operating room technician handing instruments to surgeons. And prior to that, finished up college. But those are great to shape my medical career as well.
Justin (03:01):
Yeah, absolutely. So what, what would you say is the focus or the, you know, specific expertise at the Javery pain Institute?
Dr. Suderman (03:08):
Sure. Our focus really is patient-centered. You know, we take the time, we make the effort to develop that deep personal connection with patients, especially in regards to pain management. You know, that’s the most common reason people see a doctor. But yet primary care physicians are really overburdened. So we want to be that outlet where the patient comes and they’re listened to. Every new patient sees the physician only on their first visit. So we establish that connection. And then throughout the followup period, months, maybe years, our team collaborates and it’s just a personal connection because we walk with pain likely for the rest of someone’s life. It’s a diagnosis in and of itself. And so our specialty is really just developing that connection and then applying those multi-disciplinary tools to manage their pain in a personal way.
Justin (03:53):
Got it. And so it sounds like you were pretty lucky to land at a place where you’re really happy from the beginning. I think that is an uncommon experience. So I’m curious as you were going through the process of wrapping a fellowship, trying to make some connections in the industry, trying to figure out, you know, you’ve been in academics all the way up to that point and you’re about to make a jump into a different type of practice model. How did, did you feel prepared to be able to make that decision and what kind of resources were you drawing upon in order to do that?
Dr. Suderman (04:18):
Right. I think looking back, no one ever feels as prepared as they would like to be to make a decision about a job. Just like anything in life choosing a major in college or becoming a parent or, you know, major decisions, you never feel prepared. And looking back you’re like, Oh my goodness, I knew nothing. But I had great alumni from the university of Michigan to rely on people in private practice, pain management. I actually found a contract lawyer in the town where I was working at and she kind of helped put some perspective on the contract I was looking at. And you know, in the end I’m just grateful that I’m here. I’m a man of faith and so I think there was a higher power involved and putting me here and I feel really, really lucky to be where I’m at today.
Justin (05:03):
That’s great. So talk a little bit about, you know, the topic at hand and the reason I reached out to you is I saw some of the work that you were doing with regards to advocacy in legislation surrounding prior authorizations. So talk to me like I’m a third grader for a minute and just talk about what is a prior authorization, why do we have them and why is it such a, I mean, for pain management it’s like a pretty, it’s an important part of your practice unfortunately. So talk about sort of how that all came to be.
Dr. Suderman (05:31):
Sure. So prior authorization is a process where we have to submit a treatment plan to be approved by your insurance company before we can get payment for your treatment. It’s a cost control mechanism where it’s reviewed prior to then allowing the provider to provide that treatment. And so in pain medicine, some of the procedures we do are fairly costly and it’s, it takes a lot of investment to something that’s with a patient 24, seven for years throughout their life. It’s not as easy as just taking a pill for a number like blood pressure, which the patient doesn’t even know about. Right. They know about pain every single moment of their life, so it takes a lot of investments to manage that. And so prior authorization just means prior to the treatment proposed, you’re getting an authorization to do it. Although as some papers are pointing out, it’s still not a guarantee for payment and the insurance companies still can deny payment even though they’ve authorized it, which is a whole new wrinkle in this ever evolving process that’s come up recently.
Justin (06:33):
Wow. I don’t think I would’ve even known that. So maybe you can take this concept and apply it to, you know, a just a, a little case study. Tell me about a recent instance when you had to do a prior off and how all that unfolded.
Dr. Suderman (06:43):
Sure. A recent instance is actually 100% of the time. If I need to do a spinal procedure in a patient’s insurance company uses the prior authorization process, I have to say, if I want to do an epidural, please give me authorization and we allow three weeks unfortunately to wait for that. That’s the typical time frame. And that means that if I want to treat sciatica, meaning back pain going down your leg from a disc problem I have to wait three weeks no matter how much pain you’re in. And I have to be able to say that, okay, I’m going to ask for this. I’m hoping it will happen and I have to then put in my note if I don’t think you could tolerate physical therapy. I don’t want to prescribe it cause you’re in too much pain if I don’t think an x-ray is going to give me information that I can act on clinically versus an MRI, which shows me much more detail and I have to explain that and we have to wait for that to go through the rigmarole of often Timbuktu Iowa somewhere with someone who may or may not have a medical degree to approve that based on an algorithm that wasn’t developed for you is developed across the board.
Dr. Suderman (07:49):
And then maybe we can treat you
Justin (07:51):
Right. So I was describing it before we get on this call. I had a recent experience with prior auth and it’s so funny, I keep having this experience as a patient and then I interviewed somebody about this, but I was having an issue with my back and there was a mild disc herniation. And so I was having a lot of pain. Finally went to the doctor. I thought it was muscular at first and it just, the pain kept sticking around and it was radiating around to the front. And I was like, Oh, this feels weird. So went to the my family practice doc, they were able to get me on short notice and I was about to leave town. So right now I’m in central Oregon with my my inlaws and I was going to work, we’re going to be here for weeks, so I had to get treatment done before I left town.
Justin (08:34):
And the doctor recommended an MRI and she said, I think, I think you need an MRI except I know that we’re gonna probably need a prior auth and in order to get the prior auth we might need to do an X Ray first. So it’s basically, she, it was clear to me, she had been down this road before, so she’s like, here’s the end and here’s the hurdles we may have to face between here and there. So I need you to go get an X Ray as part of the prior authorization process because they’re not going to let me give you an MRI until you’ve had a negative x-ray first. Potentially. So I went and got the extra and my physician was very responsive and I was actually able to get this done in a pretty short amount of time such that I went to the doctor on Wednesday, got the extra on Thursday, got the MRI on Friday and then left town Saturday morning. So it just so happened that in my instance in order to get the MRI it worked out. But it’s not hard for me to imagine. Oh go ahead. Yeah,
Dr. Suderman (09:28):
But, but you know what though I think it didn’t work out and I think it’s not working out because if you look at that scenario, why is this a cost saving measure to make you go through hundreds of dollars of an X Ray that isn’t going to change clinical decision making should you have to wait for that step therapy if it’s not going to change a single thing your doctor is going to do. And this entity that is the prior authorization company says, Oh, you know what? We’re going to save costs. How are they saving costs for any of that? When the your age, I mean this is evidence your age, it’s a disc problem, 30 to 50. We know that discs are the first problem that go and they cause pain going down your leg. It’s probably [inaudible] the way you described it. And we know that an MRI is actionable evidence to do something about it that’s evidence-based. The need to get an X Ray first or make you go through six weeks of physical therapy that’s not evidence based and that rarely works for patients when I can treat them with procedure.
Justin (10:27):
Yeah. And I can only imagine if you took a more extreme version of my issue where it’s like I was insignificant pain. It wasn’t like debilitating, but I was very uncomfortable to the point where I could barely buckle my seatbelt in my car when I’m driving
Dr. Suderman (10:40):
Or ride in an airplane to Oregon.
Justin (10:42):
That’s right. Yeah, that’s right. So I can imagine if it was something more acute and if the prior auth takes longer, it’s, it’s, it’s one thing for you. It was acute, right? Yeah. Right. I tried to be a tough guy so, well sure, sure.
Dr. Suderman (10:59):
We are a lot of us try to be, that’s your function, that’s your life. You can’t support yourself in the way that you could or slash be safe in a car buckling a seatbelt if you can’t get treatment. And why put the requirement for costs increasing on a patient in time because time is the most valuable resource.
Justin (11:18):
Yeah, absolutely. So, you know, from a cost containment standpoint, this would be the rationale from an insurance company is that we’re going to have all these doctors who don’t have skin in the game, like they’re not paying for this. They’re just saying, go get this thing, this scan, this treatment that may cost thousands or maybe tens of thousands of dollars. And they don’t have enough of a check to, to push back against times at which that might not be appropriate. And therefore, we, the prior auth committee of this insurance company wants to review because we, the insurance company, you’re going to be footing the bill for this thing. We want to make sure that it seems like it makes sense. So I’m curious to hear, you know, what’s the, what’s the response to that?
Dr. Suderman (12:01):
Right. So that’s the common verbiage in the lay press. And every single part of that statement is actually 180 degrees backwards. So first of all, this is not done for cost containment because the insurance companies had got wind of that. And I was at a hearing and Lansing, our Capitol here in Michigan where an insurance company talked with senators and they said the word cost containment zero times they said, this is for to ensure safety. This is to guard against outliers who are going to over-utilize the system. If that’s the case and it’s not cost containment, then why am I required to do this every single time for procedures that have been done for decades on millions of people and are very safe. So it’s not, you know, it is cost containment and it is that, first of all, and I’ve actually talked with another insurance group here in town and said, yeah, yeah.
Dr. Suderman (12:49):
So the burden of price actually does fall significantly on the provider in an indirect way. Cleveland clinic in 2017 they spent over $10 million of their own money doing this. The healthcare system providers are hundreds to billions of dollars over one to two years based on a CAQ H. It’s a nonprofit Alliance that looks at this data every prior auth costs, almost 20 bucks and that’s put it by me because I’m paying staff right below me as the vice president, part owner of this company to process these and it’s been shown that one provider takes two to three FTEs of people to process. This. Henry Ford health system is here in Detroit. They have over a hundred people just doing prior offs. Insurance company isn’t footing that bill. We are. So if the insurance company is concerned about footing the bill, take this out and then don’t make me order useless tests that are going to cost you money and when I want to do a spinal procedure, don’t make me prescribed six weeks of physical therapy, which certainly costs more than epidural and finally I’m required to order an MRI annually without clinical indication. They just say we need an MRI every year. If we’re going to authorize another treatment, there was no indication for that. And they can’t do procedures in your neck and low back on the same day if you have arthritis in both. So the patient’s coming back, not bundling, paying for both procedures 100% and their driver and them are both missing work. That’s economic cost.
Justin (14:19):
Absolutely. So talk about the, the experience at the Javery pain Institute. What kinds of, you know, you just described it a little bit. What kinds of infrastructure in terms of staff systems, you know, the form emails that you send is like, well, we’re going to send this email, then this is going to come back and then we’re going to send that email. Like, describe what you’ve had to do in order to deal with this.
Dr. Suderman (14:40):
Yeah. You know, boy, it’d be nice if it could be emails, but so often it’s faxes. Just like in 1985. Yeah,
Justin (14:45):
That was a good year in 1985 years old
Dr. Suderman (14:49):
Boy, back to the future. Wouldn’t that be great? Well, not in this instance. Right. so the big thing here now is wow, we’re going to make this all electronic. That doesn’t matter. I’m still have staff on the phone for hours at a time waiting to get in touch with someone electronically to process this. So we have the billing department of five to seven people with two physicians and two of those people are working on prior auth only. And so we’re a little clinic but you know, I guess that means we’ve got job security if you’re for people in the, in the community here and we can feel good about that. But it sure costs a lot. And we have a billing department though that’s trained to really hone in on these pain management practices. Our billing department coordinator has been doing this for 30 years so they know how to get these through and we know how to preemptively document. So the things I was saying to you, I put that in my note. If you were my patient, I would put in my note, Justin needs this MRI in this treatment because your clinical history, your age group, your symptoms, and I believe this is the best indicating treatment rather than step therapy.
Justin (15:52):
Right. So does just prior authorization and the headaches associated with it, does it vary by payer or by insurance company or talk a little bit about that.
Dr. Suderman (16:02):
Oh yeah. Oh yeah. Everyone in our clinic down to the medical assistant, probably even the front desk, we have flags on the chart. We know when it’s a prior auth insurance. And so there are third party companies for profit companies. One of them called Evacore EDI, C O, R, E who contract with not for profit companies, like maybe a blue cross or whomever essential, I don’t know if Ascension’s you know, a for profit but somebody else. And Evercore, the for profit company gives them the guidelines for cost savings. So then we know, Oh, that policy is governed by Evercore. So now we know it’s going to be a totally different conversation with that patient and we’re not going to be able to offer as timely of care as we could with other insurance companies. Medicare is great. We don’t need prior auth for them. Imagine that a government insurance company being more easy for, easier to deal with in commercial, but not all in commercial insurance companies are governed governed by a prior auth process. It depends on who they’ve contracted with.
Justin (17:02):
Got it. And then do the prior auth requirements vary? Cause I know insurance is regulated at the state level. I think, I don’t know if it’s the same with health insurance. Is that, does the prior auth requirement vary by state? Do you know?
Dr. Suderman (17:15):
Yeah, so we are actually working with that here in Michigan. Senate bill six 12 is here and we, we worked with this last week at that hearing. They do have ways to govern how commercial insurance carriers do this. So one of the big things is prohibit an insurance and insurer from requiring that an insured persons participate in a step therapy protocol. So they have the power to say, you can’t do that in this state. Now in general, state legislatures have more control over Medicaid dollars. But we don’t see a lot of straight Medicaid because it’s somewhat transient way is where you know, you’ve got to get on and they want you to get off and you know, do more in life and all that. It’s a big debate. So there is some control over that at the state level.
Justin (17:59):
Okay. So talk about your what’s happening in your home state. Cause obviously in Michigan this has been, it’s a legislative front burner item that’s happening in real time right now and you’ve been involved in that public discourse. So talk about what does the state of affairs and what have you been doing?
Dr. Suderman (18:15):
Well, we’re lucky, I’m Senator Vanderwall is the chair of this committee. He’s really listened to physicians and our state medical society. The Michigan state medical society has created an initiative. It’s a health can’t wait. And so if you go to health, can’t wait.org. That really summarizes our efforts here in Michigan. There’s a lot of good information there. And basically we want transparency, right? We want to ensure that if we’re getting a denial that we’re talking with a doctor who’s licensed and board certified in our specialty. I tried to talk with internists and radiologists about why I need to do certain treatment plans and a radiologist has never seen a patient in their life, right? So how can they tell me as a pain management doctor what I should be doing? Other parts of this. As I said, if step therapy doesn’t apply to you, then the doctor needs to document why and then be approved for that. And then if there’s going to be changes, Hey, we need to know about that beforehand and they need to be in an easily accessible place online. Basic things that we’ve got since 1995 we’ve got this thing called the internet where people can go on and they can look at things pretty easily. It should be able to see that and process this pretty quickly. So these are basic things we’re asking for in 2020 and I’m hoping to make some progress.
Justin (19:25):
Great. Do you have a sense for where Michigan stands in terms of like how progressive it is as far as like an acting some of these policies?
Dr. Suderman (19:34):
I have not talked with other state legislatures. I think as you mentioned, this is a front burner issue and I think a lot of people are just getting into this because in our field, so much of it has been the opioid epidemic for so long. I have not got a sense from our state medical society about the AMA national level feel of this, but the AMA at a national level is pushing these same issues and progressives. So it’s happening nationally, I don’t know, state to state as well. And we’ve got it. We’ve got our hands full here.
Justin (20:04):
Yeah, no kidding. So there was that article in the Detroit news which I cited in the first email that I sent ya and we’ll, we’ll link to in the show notes. So for our listeners, anesthesia success.com/ 36 we’ll link to some of the great work that Josh has been doing and some of the sources we’re going to discuss here. So the Detroit news had this stat that it was something like 97% of prior off, first prior off requests ended up being approved. So 97 out of a hundred. And so, you know, what does that, what does that tell you as you’re looking at the landscape here?
Dr. Suderman (20:40):
So that should inform what we talked about a few minutes ago. Your listeners now know the state of affairs in that this is not a issue or an outlier issue. This is cost containment. So if you really feel that we aren’t doing the right thing by cost for safety or outlier, then why are we approved 97% of the time? And here’s the answer. It’s because we’re asking for routine care to be authorized. Transfer Amatol epidural steroid injection, right? This is a procedure that’s been around for decades. It’s something I’ve done thousands of times in my short career. I do it every day. And so the reason it’s approved that much is because we’re required 100% of the time to submit this off. And I guess there’s 3% of the time where someone doesn’t need, I don’t know what that would include. I would hope as a pain management certified specialist, I could tell when they need this most common procedure. That’s the reason is it’s not for out of this world crazy things. It’s everyday care that now all of a sudden has this other layer between the patient and the physician. And that sacred relationship doesn’t get to make the call between patient, patient and physician any longer.
Justin (21:41):
Yeah. Another stat cited here was that there was an AMA survey that said 28% of physicians reported that prior auths had resulted in a serious adverse event including hospitalization, permanent disability or death. So that’s another one of those startling like prior author. Literally it sounds like literally killing people. Yes.
Dr. Suderman (22:00):
So in my world, I treat elective problems, right? We’re in, we’re in an office out on an, in an office park. So I am lucky in that I don’t deal with life or death, life or death situations. I can’t speak to that personally. But what I can speak to is that patients see pain that way. People see pain as life or death and they’re not going to be able to do the things. And so if you think about adverse events, well that person who has to deal with it for three weeks beyond what I could normally treat it meaning the same day I need them. That’s certainly an adverse event. And that gets into some of the other statistics where you know, a majority of physicians believe this has led to delaying of care and even abandonment. Yeah.
Justin (22:38):
Yeah. I mean, I can imagine in my own situation, if, if it hadn’t been that I could get the MRI literally on the day before I was going to be out of town for three weeks and now I’m in central Oregon where I don’t have access to any of my normal sort of medical infrastructure. I would probably just be taking lots of ibuprofen for the next month and hoping that by the time I get home, it doesn’t hurt anymore.
Dr. Suderman (22:58):
And here’s where it leads into the opioid epidemic. Because if I can’t get authorization for opioid sparing treatments, then how, what am I being asked for? Well, you know, doc, what can you do in the meantime? Right. Well, what can you give me today? Well, you know, I’d like to be able to do this procedure because it works. And I can put medicine directly to the source of the problem. But today I can’t, and this gets back to kind of that historical thing with, you know, advocacy, you know, I noticed even before prior auth, that insurance company formula varies, make it so easy to write opioid medications like the allotted fentanyl, morphine, hydrocodone, and they don’t give me access to new or use of medications like buprenorphine, which is a safer opioid medication. And so that is in parallel and they just feed off each other. If I can’t treat you now, then you’re going to be asking me for things that I feel are unsafe, then you’re going to think that you can’t trust me as a patient. And then where’s the trust? Where’s the relationship? And there’s an adverse event. I don’t know where you go to get your care any longer cause I can’t give you care. Right.
Justin (23:56):
Talk a little bit about how, how did you begin to get involved in the advocacy side of things? And if somebody else out there is listening, who’s like prior auths are making me pull out all my hair and punch holes in the wall and I want to do literally whatever I can to try to push back against this. How do I start to take that first step? Sure.
Dr. Suderman (24:11):
My history when I started out Medicare started to put some restrictions on epidural injections. And they were just blanket restrictions. You can only do this much at a time. And some physicians would agree with it, some wouldn’t. It was just the fact that, Oh my goodness, like I wasn’t, I didn’t see this in the ivory tower of academics. You can’t do what I think you should do. So I just emailed our LCD there’s different regions of Medicare in this country. So I emailed them and started talking with them. And then the opioid formulary issue spurred me on as well. And so what I’ve done is I’ve really just taken it on myself to contact my lawmakers over and over and over again. I got a few of them to visit our clinic. I went up to this hearing in Lansing.
Dr. Suderman (24:53):
And then through my state medical society, I’m really fortunate that we’ve got things like this health can’t wait initiative. They can plug me into lawmakers as well. I’ve tried talking with insurance companies, I’ve met with other pain groups in town and we actually sat across the table from them. It was just not productive. This know third party company was there and between us and the insurance company, and we were literally told at one of these other meetings as well, you know, we’re, we’re a guideline company, we do guidelines, we don’t do patient outcomes or satisfaction. So that kind of shut me down. I’m like, well that’s a wall. I can’t really bark up anymore, you know, or try and climb up if that’s their view of it. So you know, it’s really been advocacy through legislation and then getting in touch with other doctors who have the same issues.
Justin (25:40):
So you mentioned the health can’t Wade initiative in Michigan. Tell me a little bit more about that.
Dr. Suderman (25:45):
Sure. This is born out of the Michigan state medical society and this initiative is specifically for prior authorization. So, you know, the American medical association, kind of the parent association, Michigan state really brought this to our attention. And then people in Michigan verified that, Hey, we’re having these problems that’s right here in Michigan. And so this is a coalition of dozens, literally dozens of different organizations here in Michigan. You’ve got all these logos here from physical therapists to radiologists. We’ve got anesthesiologists, the diabetes association, cancer action network a different County medical society, sickle cell disease of America, Susan G Komen. So all of these groups, patient advocacy groups, physician groups, all see the problem with prior auth. And this initiative has given them a common Avenue to address those concerns.
Justin (26:39):
So if there’s such broad based support, why, why does this, why, I mean there’s a number of places in healthcare where this question would apply and it’s a little bit rhetorical, but why is it taking so long and why is it so hard? The status right there, 97% of first prior auth requests get approved that says like statistically only won three out of a hundred would ever even get denied. And is it not worth letting three out of a hundred perhaps slip through to a more progressive treatment if we can, you know, get rid of a whole department worth of people that are just generating a bunch of work that delays patient care. Does that not make sense?
Dr. Suderman (27:16):
It does. And I agree with your hands going everywhere and you get an exasperated for people who are just listening here. That was a great explanation. I’m going to call you out on that, Justin, because it looked great. It, it totally reflects patients, physicians, providers, healings on this. The answer is, you know what, we’re not in control. The way our health system was allowed to develop the insurance companies control this. And it was interesting there. There’s a vision, there’s a picture in my mind when I went to the Senate building in Lansing and I walked up to, I was walking in the door and I looked kinda up and behind it and I saw there was this other big larger gray building towering over this Senate building. And the logo on that building was a national insurance carrier literally right next door connected.
Dr. Suderman (27:55):
And that shows you how in the midst of the Senate building, it’s being dwarfed and hovered over by an insurance carrier. And that is, I think is a good example of where we stand. And, and, and that’s why, and we need patient voices is the first and foremost. Cause that’s the most powerful thing here. And that’s starting to happen. And I think that’s where we can bring this change about. Also we need collaboration. And I can bemoan insurance companies all I want, but until I can provide a solution and work with them on that solution, I’m not doing the responsible thing here. So you’re getting background and my frustrations, but you know, doctors want to be at the table. They want to sit with their patients as they did in front of those senators and talk about this and come up with a solution so that we can kind of bring our hands back in and start pulling out our hair as you said, and get down to business and make healthcare better.
Justin (28:41):
Do you feel like the physician organizations advocacy groups, are they doing a good job right now? Are they doing an adequate job of exerting influence in this direction or are they maybe spread too thin? Are there other issues or do you see this as an area where there needs to be more focus?
Dr. Suderman (28:57):
Yes, this needs to be more focused. Listen, we as physicians, we’re trained to care for patients. We don’t learn advocacy, we don’t learn business. And those are the levels where decisions are made politically for the care that we deliver. And traditionally it’s just because we haven’t done a good job of getting involved because we’re maxed out on giving away the twenties and thirties of our life learning to care for patients. So we need to do a better job. It’s not because we aren’t trying, but we need to. We need to get doctors trained. I would love to share my story and my success stories and what I’m learning both in administrative and advocacy roles because that determines what we can do. And that’s just the reality of it. We can’t just, you know, say what we need for our patient and expect that to be authorized and there’s some good in that we should learn population health. We should learn what it means to get a good staff around you and then treat that pain with evidence based practices, best practices when they’re available. And so doctors are okay with that. We’re not scared of that, but this isn’t, it’s not working and we need to do better than prior authorization allows us to do.
Justin (29:59):
So. I know for a fact that there are other there’s physicians in state societies and some of the national organizations listening to this probably right now. You ha you have their ears. So what do you want to tell them as far as how do physicians work together to be able to care for patients in sort of modifying the current prior auth environment to make it more friendly for treatment,
Dr. Suderman (30:21):
Right? You get yourselves together in your state, right? Come up with reasonable demands that are based on evidence, based on patient stories. Go to your state society or go and, or go to your legislators, talk to them about this. They want to hear from you, your, their constituent as well as your patients are and, and make them aware of these issues, band together. And then me, I’m kind of in the middle. I’m not starting off on this, but I’m also not an expert. So those of you out there who have experience with this, if you’re further on in your career and have seen please, please, please give to us coming behind you to empower us to say, Hey, you know what, as physicians, we haven’t been able to do this. This is where I’ve seen that could have been done better. And find some young doctors, you know, maybe like myself, maybe I’ll Pat myself on the back a little bit who are anxious to do this and have some zeal for it and who are willing to take a clinic day and go up to Lansing or your Capitol, wherever it is.
Dr. Suderman (31:16):
And, and talk with legislators. We need to collaborate. We need to talk together more. Not just kind of, you know, pick out what one doctor’s doing versus the other or, you know, nitpick at that insurance company. Be prepared to sit down with people quote unquote across the table and, and make some, make something happen. Make some changes for the better.
Justin (31:37):
Do you see any anything happening at which you are encouraged in this, in this discussion?
Dr. Suderman (31:45):
Hearing that I went to was encouraging the senators in our state on this specific committee. You know, all politics is local. They, you know, they want to hear this and they want to listen to doctors. I think they understand that doctors have patients’ interests in mind. And so legislators, they’re gonna listen to dollars and they’re going to listen to the voices, their constituents. Physicians, we don’t really have a calling card for, you know, whining about this stuff. You know, they aren’t going to really take video on, on physicians. We’re, you know, I think alone physicians alone. But if we can combine it with patient stories and the ways that we’re trying to save them dollars by not having their patients go to the ER for pain, exacerbation and cost, you know, the employers who contribute to their political campaigns a lot more money. Then that’s the angle that I think we could take. And I think that’s starting to work here and we’re getting a good audience. So that is encouraging.
Justin (32:38):
Dr. Suderman (32:40):
Are there any other important questions to address or facets of this issue that I haven’t already asked about that it’s worth worth mentioning? Right. I mean, I think we’ve addressed a lot of the reasons. Okay. We addressed the history of prior auth. You know, why it’s important and what limitations it puts on care. But I think two things, the collaboration is important here. Let’s not just call people out. Let’s not just, you know, give the insurance company that building behind the Senate, building a bad name. I’m, I’m ready. I would love to walk in that building and have a productive conversation with people. And, and understand, because the funny thing is some of those people were doctors once themselves and cared for patients. So let’s, let’s come together. Really, let’s be collegial about it and, and make this happen. You know, the other thing too is if, if you want to look at it this one way, if you start with why quote unquote, it’s Simon Sinek, he’s a marketing guru guru.
Dr. Suderman (33:28):
I love that book. And you know, you have to look at the values and the beliefs where people are coming from. Why are we doing this? From there you can get out to the how we go about this and then what we’re trying to get against. But you know, the values of why are we in this and, and doctors and patients. You know, we’re here to help people for me get their life back, right? We want to help people function with chronic pain. I’ve heard directly from other companies who put out these guidelines that, you know, we don’t do patient satisfaction, we don’t do outcomes. We’ll only do guidelines. So let’s bring our Ys together in a better way. And I think we need to do that across the table, across, you know, all these different things. The involved parties to make improvements here.
Justin (34:09):
That makes sense. And I’m curious to know what you think about this. I think that in this day and age we are, we’re just, at least this is, I think there’s all these big companies, the big social media and internet driven companies that their, their profitability is directly correlated with how divided and how fractioned and factioned they can make American citizens and the rest of the world. And so there’s incentive to just drive the wedge deeper and, and make us more and more feel like we have an adversarial relationship with everyone because it makes us read the article and comment on the post and then they can sell us more ad dollars. I’m a bit of a, you know, a conspiracy theorist in these ways and I just see these relationships and it’s kind of, it’s undeniable in my opinion. But anyway, I think that one of the antidotes potentially to, I think this is an issue, you know, we can pit insurance and like doctors against each other.
Justin (35:01):
It’s like, Oh, big bad insurance companies and greedy doctors and whatever. I’m curious, do you, do you see any opportunities to build human connection across the aisle? If we say the other side of the aisle is maybe the insurance industry, are there, are there people over there or are there discussions between physicians and insurance companies happening anywhere or could there be that that would help sort of break down the the stereotype and the facade and say human to human, we all want to live in a better world. Is there a way to, is there a way that we can do that and like you said, work together to be able to help
Dr. Suderman (35:38):
Your, your image of driving a wedge is a, is accurate because if you think about the physician and the patient, if there’s a wedge of prior auth, that is a cost control for-profit mechanism that the insurance company uses. So you’re exactly right. That wedge there. If you take it from that really personal thing and then balloon it out to population, I think that’s applicable. And yes, there are opportunities to do this. I have, there’s a more local insurance company in our area. We meet with their senior vice president medical officer about once every two to three months. Just me and dr Jaber here in the clinic. We talk about pain management and prior auth and you know, we feel really lucky to be able to do that and inform him he was a previous doctor and even physician’s assistant and when that happens and it works really, really well and it’s really cool to see policy come out of those meetings.
Dr. Suderman (36:24):
The centers for Medicaid and Medicare and Medicaid services. Dr seeing the sing I think is her name, she’s the administrator. She put out an article recently about, you know, driving down costs and giving patients and doctors, you know the chance to make their own choices and Medicare and medical care. But she also said that, well, prior authorization is here, so we’re going to make it electronic to make it more efficient. But you know, it’s still here. That was a little bit, you know, hypocritical to me. But in that article she said, we’ve had over 2000 people give comments at 35 listening sessions. So that was really encouraging. The thing is, doctors and patients have to feel like we’re having an impact. And there’s a foothold in that. What we’re going to say is going to be listened to and that we can find a middle ground here. I’ve tried that, as I mentioned at a different insurance company, took an evening with a lot of other doctors and all we heard from was not even the insurance company, but that third party prior off saying this is the way it is. I’m sorry so it can work.
Justin (37:26):
That sounds deeply frustrating.
Dr. Suderman (37:28):
Very. That was an awful evening.
Justin (37:33):
I had another question that just slipped my mind. Oh, you mentioned something earlier that I want to come back around on the instances where there is a prior auth and then the treatment that gets approved ends up not being paid for by the insurance company. Can you talk a little bit about the circumstances surrounding that?
Dr. Suderman (37:47):
Sure, sure. So there are a couple of articles out there. One’s in gentlemen network recently from earlier in February. And there are instances also Kaiser health news, one of their recent articles. If you search for this there are patient stories out there and, and this gets to conditions that are almost, are more life and death, serious diseases, pain is a problem, but these are even more serious in some ways where, and this is in the language of prior auth, an insurance company will say, your care is approved, but this is not a guarantee for payment. And so then they come back and say, well, you know, we’re actually not going to pay for this. And those articles didn’t tell me the specifics of why it’s just that this is happening. And you know why you can’t say that, you know, this is not cost containment when all of a sudden you’re, you know, asking for every procedure to be authorized. And if you take it another step further and put that cost on the patient, as these articles are pointing out that’s agregious and it’s just obvious why we’re doing these things and we have to be able to make a better system primarily for patients, but also for the provision of healthcare in general.
Justin (38:51):
Yeah. Makes sense. So as you look to the future you know, in the next say like three to five years, Josh, and what, what kind of, what kind of future do you envision for pain management physicians for their patients and for healthcare more broadly as hopefully we continue to, you know, push back against these parts of the, I mean, healthcare is like big and confusing and opaque. The more I consider myself pretty well versed and the more I dig into things, sometimes I just have to scratch my head and think, is there, is there literally anyone in America that knows enough about the big picture and cares enough to be able to, to like productively improve this? Cause I feel like there’s so many stakeholders and it’s so, you know, everyone’s kind of pulling in opposite directions, but what do you think progress would look like, you know, into a three to five years from now?
Dr. Suderman (39:43):
Those dynamics will never change of course, but I think to make progress move forward, we need a few things. We need, you know, physician collaborators and leaders who understand both sides of this advocacy, administration, clinical care, and blending that in only a way that a physician can. We have to understand that there will be population health guidelines that we operate by. We’re okay with that, we want that, but have that be from our clinical societies, you know, let us argue that out and then give us the freedom to operate by those. But if not, say Hey, okay, this is why I think we need this unique thing because those are guidelines. They can’t determine every patient situation and then get physicians to the table to understand, okay, if your value based practice maybe is a little more costly than someone else’s, right.
Dr. Suderman (40:35):
Don’t say you can’t give that care for three weeks and then potentially put the cost on the patient. Let’s talk with doctors about what does that mean to operate within that system. I don’t have those answers, but doctors need to be a part of that rather than just slapping a prior auth seeming fix on this. And so in three to five years, if we can get to where physicians are at the table, making more nuance, the availability for more Yuan’s to treatment options, we’ll be successful as long as we keep our why in front of us of patient care, common values and beliefs, right. And as long as we collaborate and I’m just as frustrated with you with insurance companies and all these things here, but at the end of the day, I have to remember too, there are people just like you and me, people, people, people is Renee Brown, so she’s a great motivational, motivational speaker, organizational development guru. We’re all people, people, people. So if we can talk to each other that way, and I have to remind myself every time I post something on LinkedIn or talk about this, that’s going to be a foundation where we can come up with common wise and values. And then the patient’s really just going to benefit because we can deliver great care and we’re going to get great outcomes, great satisfaction for great value. That’s the triple aim of healthcare.
Justin (41:45):
Yeah. Well, I really appreciate the work that you’re doing, not only for your patients, but to try to create a system that’s functioning better on behalf of everyone who’s a participant in it. So Dr. Josh Suderman, thanks a lot for your time today on the anesthesia success podcast.
Dr. Suderman (42:01):
Justin was great, had a great time with you. Thanks for this opportunity.
Justin (42:05):
If you liked what you heard this week, head on over to anesthesia, success.com where you can find more content and free resources to help you build a successful career in anesthesiology and pain management. If you want to leave a review in iTunes, I would also really appreciate it. Thanks for using some of your valuable time to join me today on the anesthesia success podcast.