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Op-Ed

How New Medicare Pre-Authorization Could Deny Care, Increase Inequality

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Starting next year, Medicare will initiate a new program known as the Protecting Access to Medicare Act. It will require electronic pre-authorization, based on professional society guidelines, for imaging procedures such as MRIs.

The program aims to reduce unnecessary testing and expenses, but it could reduce access to essential procedures and increase health care inequality.

In the best-case scenario, PAMA will increase red tape and reduce physicians’ already limited time with patients. That’s bad enough.

The worst-case scenario is a nightmare: mandating outdated guidelines, exacerbating care disparities, degrading the doctor-patient relationship, and eliminating the right to appeal bad decisions.

One of PAMA’s biggest problems is an overreliance on professional society recommendations. Many “expert” recommendations may be little more than opinion based on scant scientific evidence.

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Another problem is that guidelines frequently change to incorporate new knowledge, but revising guidelines is a long, involved process that can lag behind the latest evidence. Conflicts frequently emerge between professional societies, or even within the same professional society, by the time a revision is complete. Consequently, guidelines may recommend something that has been disproven or advise against something that has been proven.

This isn’t an assault on guidelines in general, as they can be helpful in assisting physicians with complex decision-making. But guidelines were never intended to supplant clinical judgment — which PAMA would do.

Once PAMA is enacted, if an orthopedic surgeon orders an MRI but a professional society doesn’t recommend it, then Medicare will not approve or pay for the imaging. This dismissal of the physician’s clinical judgment could result in delaying treatment, unnecessary pain, or even further injury.

The new rule may also increase income-based inequalities in access to health care treatment outcomes. Seniors who can afford to pay for tests out of pocket may simply do so. For the poor, however, the unapproved MRI may be out of reach.

Patients who can’t afford to pay out of pocket could have more undetected cancers or other serious conditions. They also may suffer more pain and limited mobility until the tests are approved, if ever.

PAMA will thus create two tiers of patients: those who can pay for the imaging their doctors recommend but that Medicare disapproves, and patients who can’t. Those who can pay out of pocket will have a meaningful discussion with their doctors about the recommended test’s benefits and risks. Through a shared decision-making process, the patient and doctor will choose whether to pursue the imaging.

Meanwhile, patients who cannot pay will be left at the mercy of an electronic algorithm, which will decide for them.

These discussions, and the shared decision-making process, have wide-ranging implications. Patients who engage in them are more satisfied with their doctors, more likely to follow recommendations, more likely to complete preventive screenings, and more likely to take medication as prescribed. They even live longer.

By contrast, patients whose case has been predetermined by Medicare won’t have such conversations with their doctors — or reap the benefits that statistically follow.

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PAMA, and therefore Medicare, would do a poor job choosing whose imaging should be covered. Many guidelines take the age of the patient into account when issuing recommendations.

For example, mammograms are recommended only at certain ages. But people at a given age are not a homogenous group. They range from healthy and spritely to knocking on death’s door. These extremes should obviously not be treated the same for screening and testing purposes, but PAMA would prevent Medicare from making this distinction.

Even worse, the Medicare pre-authorization system might exclude appeals. Most, if not all, health insurers have pre-authorization requirements. All private insurers have a “peer review” process — where the ordering physician can explain a patient’s circumstances, possibly receiving approval for the requested test or procedure. That might not be the case with Medicare, where the cold, impersonal decision of the electronic algorithm might be final. Patients who do not fit the criteria exactly may be denied access with no recourse and, if they cannot pay out of pocket, bear the grim consequences.

Ironically, the advocates of a single-payer system highlight how income inequalities impair health and longevity. They propose Medicare for All as a path to health equity. But PAMA alone — which is a tiny dose of Medicare for All — would exacerbate inequalities. PAMA and other cogs in the single-payer machine would be cures worse than the problem.

The views expressed in this opinion article are those of their author and are not necessarily either shared or endorsed by the owners of this website. If you are interested in contributing an Op-Ed to The Western Journal, you can learn about our submission guidelines and process here.

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Chad Savage, MD, is a policy fellow at the Docs 4 Patient Care Foundation (D4PCF) and the founder of the DPC practice YourChoice Direct Care in Brighton, Michigan.




Gabriela Eyal, PsyD, is a D4PCF policy fellow and a licensed psychologist in Lansing, Michigan.




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