In theory, the application of evidenced-based guidelines assists in reducing unwarranted variation in clinical practice and improving the quality and cost of care. Guideline developers, health plans, and their benefit managers contend that utilization management programs based on medically proven guidelines will transform the health of our communities, one person at a time.
Utilizing the services of physician (and nurse) advisers, guidelines are deployed in the medical review of complex, controversial, unusual, new, or experimental medical services involving proposed surgery, imaging, pharmaceuticals, devices, and various procedures. The length and level of service -- for example, hospital, skilled nursing facility, outpatient treatment, and the like -- are also subject to review. All this activity falls under the umbrella of utilization review (UR).
UR companies cannot exist without physician advisers. It is generally accepted, and in some instances mandated, that only a physician can deny medical services (technically, medical benefits). And therein lies the rub. Most practicing physicians detest being subjected to UR procedures -- completing forms and responding to time-consuming peer reviews. An American Medical Association (AMA) found that, on average, physicians and their staff spend 13 hours per week (nearly 2 business days) completing prior authorization requests, which represent only a subset of UR functions.
No one knows the number of U.S. physicians working for utilization management organizations, but it is becoming increasingly popular because companies offer flexible hours and remote working opportunities. The work can be full time or as a contractor, leaving time to continue to see patients.
I used to believe strongly in the importance of UR and the tenets of utilization management -- increased quality and decreased costs. I even worked for a few organizations earlier in my career. I left because I could no longer support the premise that managed care was better than care as usual, and because I questioned my right to tell another doctor how to practice medicine. The more I sympathized with my colleague on the other end of the telephone line, the more I tried to help them fulfill their request for services for their patient, regardless of the UR criteria.
One doctor thanked me for helping him document the clinical rationale necessary to extend time in the hospital for his patient. He called me an industry "insider." He said it was meant as a "compliment" because he was amazed I still cared about patients. This doctor's "compliment" insinuated he no longer perceived me as a helper, that I was no longer worthy to serve the suffering. I believe that most individuals who become doctors do so with a deep desire to help people heal. Yet, in my case, my purpose had become lost upon my colleague, and perhaps myself as well.
Another issue that plagued me was my psychiatric training, which qualified me to review mainly patients with psychiatric and substance use disorders. Nowadays, there are a host of companies contracted by payers to conduct specialty reviews in diverse areas ranging from behavioral health to orthopedic and spinal surgery to oncology treatment.
Shouldn't physicians who sub-specialize in a particular area of medicine be reviewed by equally qualified physicians? Matched specialty review has become a highly controversial topic. Specialty matches are usually required upon appeal of an adverse medical determination, but not for the first level of review. Still, I doubt that a cardiothoracic surgeon would have wanted me denying -- or even approving -- her proposed treatment.
Discussions with treating providers to clarify clinical information caused me considerable anxiety. I cringed at the thought of having adversarial peer-to-peer calls with other physicians. I also had misgivings about HIPAA when it was enacted. Although peer review conducted through the proper channels falls into the exception for , common pitfalls exist that may expose physicians to HIPAA liability.
Indeed, one physician challenged my authority to conduct peer review. Nevertheless, he complied with my request for clinical information. Subsequently, he filed an ethics complaint with the American Psychiatric Association (APA), claiming my role as a peer reviewer was unethical because I did not have his patient's permission to discuss the case. So why did he divulge the information in the first place? I was exonerated by the APA, but the experience opened my eyes to the fury of my peers.
It is not uncommon for treating physicians to intimidate reviewing physicians by asking for their credentials and licensing information and reporting them to state medical boards. Although hospital quality assurance peer review committees operate under privilege afforded by law, the same is not true for UR activities conducted by commercial entities. To the extent that such activities are tantamount to the practice of medicine, physician advisers could face licensure sanctions -- for example, if they fail to competently review the medical record, behave unprofessionally, or review a case in "bad faith," i.e., with extreme prejudice or malice.
UR jobs can be rewarding for some physicians. The excitement stems, in part, from the importance and critical nature of the physician adviser role, especially in utilization management companies scaled to impact millions of patients. The role caters to individuals interested in population health. And when you add UR companies' marketing pitch -- working virtually or on-site in a fast-paced environment that favors individuals who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives -- UR jobs seem like an ideal fit for physicians seeking a career change.
Unfortunately, physicians who drink the Kool-Aid soon realize UR jobs are a dead-end. There is little opportunity for upward mobility in large healthcare organizations dominated by the "suits," where business executives value physicians for their ability to save the company money by denying care to patients, and where women face a significant glass ceiling to advancement.
I believe fewer physicians would work for UR companies if they fully understood the burden of UR on practicing physicians and their patients and employers. The aforementioned AMA survey found that prior authorization requirements substantially delay treatment, force physicians to abandon treatment, and negatively impact clinical outcomes and work performance. I recommend physicians think twice about drinking the beverage they're served.
Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board, a 2021-2022 Doximity Luminary Fellow, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.