Preauthorization protects health, safety of HMSA members

The Hawaii Medical Service Association (HMSA) and doctors share the same goal — protecting the health and safety of people who trust us with their care. We work together to reach that goal but sometimes disagree on how to get there.

That’s the case with the Sunday Honolulu Star-Advertiser article, “Not what the doctor ordered,” in which several doctors criticized our preauthorization program that requires approval from us for imaging services such as MRIs, CT scans and PET scans.

As a physician, I’d like to explain how our preauthorization program works, how it protects our members, and how it keeps health care affordable for our community.

Preauthorizations are so common in health care that virtually all health insurers have them. HMSA’s preauthorization program has been in place for more than 10 years. It’s designed to improve our members’ health and well-being by stopping overuse of medical services that could unintentionally cause harm, and prevent wasteful services that people don’t need.

Every dollar spent on an unneeded service means a dollar less for someone to spend on essentials such as necessary health care, housing or education.

Imaging services have always been part of our preauthorization process. Many imaging services use radiation and their use must be monitored for our members’ safety. There’s national physician concern about overuse of radiation in imaging services, as reported online on staradvertiser.com (“Heavy use of CT scans raises concerns about patients exposure to radiation,” Jan. 23).

Even imaging services without radiation can be overused, leading to “false positive” findings that begin another round of unneeded and often invasive testing that creates risk and wastes people’s money without necessarily providing benefit.

That’s why HMSA and our vendor, the National Imaging Association (NIA), use national guidelines for our preauthorization policies from associations of specialized physicians such as the American College of Radiology, the American College of Cardiology, and initiatives like the American Board of Internal Medicine’s “Choosing Wisely” campaign.

Though we’ve had a preauthorization program for imaging in place for years, many doctors had been issued exceptions. A recent national clinical review by NIA shows that doctors order 30 percent more imaging services than needed. And Hawaii has even higher trends for imaging and imaging-related procedures than the rest of the nation, implying that more than 30 percent of the tests our members undergo and pay for offer no added value to their care.

These were compelling reasons to pause our waiver program so we could better protect our members’ safety, collect physician data to identify who is following national guidelines, and be thoughtful stewards of increasingly precious health care resources. Since I’m one of those physicians who lost his waiver in the process, I understand some of the unhappiness my colleagues must feel, but I also believe that it is a necessary sacrifice. Once we have information about physician practice patterns, we can reissue waivers to doctors who care for their patients with appropriate evidence-based guidelines.

We’re working with physician organizations to have physicians monitor themselves. But until that’s in place, we feel it’s our obligation. We’ve designed the interim program so approvals are given in two days or less for routine tests, it’s easy to apply online, and there’s an appeals system. No approvals are needed for emergency care.

With our preauthorization program, no one is put at risk, doctors can continue diagnosing patients and setting treatment plans, and our members’ time and money aren’t wasted on unnecessary care.

It’s a shame that the article in the Star-Advertiser did not present this perspective fairly and completely.

—

Editor’s note: This commentary has been modified since it was originally published, to include a sentence indicating the author is among the physicians who lost his waiver privileges.

Mark Mugiishi, M.D., is chief medical officer at the Hawaii Medical Service Association.