Hawaii Medical Service Association has sent letters to its physicians acknowledging the disruption its new pre- authorization policy is causing and promising to restore waivers for certain providers.

On Dec. 1 HMSA began requiring all physicians in its network to go through a third party, Arizona-based National Imaging Associates Inc., to approve diagnostic imaging tests — including MRIs, computerized tomography (CT) scans and other cardiac-related procedures — in an effort to avoid unnecessary tests and reduce costs. Before the new policy, most doctors were given a waiver, known as a gold card, that allowed them to skip the pre-authorization step.

A Honolulu Star-Advertiser story published Jan. 24 reported that according to HMSA doctors the pre-authorization policy was causing delays and harming patient care.

“I heard the frustration loud and clear in some of your voices in Sunday’s Honolulu Star-Advertiser article,” Dr. Mark Mugiishi, HMSA’s chief medical officer, wrote in the Jan. 28 letter. “We’ve tried to roll out this program with as little disruption as possible, but I know even from my own experiences as a provider who ‘lost his waiver,’ that our implementation has not been perfect. We’ve heard about issues with long phone wait times for reconsideration requests, lack of a mechanism for semi-urgent approvals on weekends and evenings, and insulting and non-informative denial rationales in communications. For these problems, I can only assure you that we have heard you and are working with our partner, NIA, to address them.”

The state’s largest health insurer — with 720,000 members and 2,800 doctors — now says the ban on waivers will be temporary while it determines which doctors are ordering excessive imaging tests. HMSA did not say how many providers would get their waivers back or when they would be restored.

“Once we have the necessary information to make valid conclusions, it is our plan to re-issue waivers to physicians who follow national standards and guidelines,” Mugiishi said. “We want what’s best for our patients. Obviously, we weren’t successful at communicating that this is HMSA’s motivation for this particular program.”

Not all doctors are convinced that HMSA intends to reinstate the waivers.

“HMSA slid this program under the table, and they meant for it to be permanent,” said Hilo radiologist Scott Grosskreutz. “They’re saying they’re going to give gold cards back. But I’m really doubtful that they will. It’s just gutting the imaging industry.”

HMSA said most physicians in its network had been issued gold cards, which is why it has “no clinical data on these cases and is unable to make any judgments as to their medical appropriateness.”

The delays caused by the new pre-authorization policy has resulted in some doctors sending patients to hospital emergency rooms to obtain routine imaging tests. HMSA’s pre-authorization rule is not required for orders in the emergency department or for inpatient procedures.

“This significantly increases the cost of health care,” said Dr. Richard DeJournett, a Honolulu diagnostic radiology specialist, in a letter to Gov. David Ige, Honolulu Mayor Kirk Caldwell and a number of senators to call their attention to the problems pre-authorization is creating for patients and doctors.

DeJournett wrote that the use of CT scans in his outpatient imaging practice dropped 33 percent in December and January compared with the year-earlier period after HMSA imposed the new policy.

“Although there may be savings to the insurance companies associated with preauthorization by denying care, there is an associated cost shift to the other stakeholders in the health-care system,” he said. “Other insurance carriers in Hawaii do not utilize this obstructive process that interferes with the orderly practice of medicine.”

In defending the policy, Mugiishi stated in the letter to doctors that 30 percent of imaging services ordered nationally are unnecessary.

“In addition, Hawaii’s utilization numbers are higher than the national average, implying that more than 30 percent of our imaging is not medically necessary,” he wrote. “I would point out that these are the utilization numbers of those who were gold carded at the time, as we were already preauthorizing those who were not. And it was this group of waived physicians who was responsible for the over utilization.”

HMSA didn’t provide specific data to back up claims about Hawaii’s high utilization rates.

An October 2015 report released by the American Journal of Radiology said Hawaii is among the 10 states with the lowest Medicare imaging spending per beneficiary.

“Hawaii physicians are doing a great job in terms of controlling imaging spending,” said Lisa Ignacio, president of the Hawaii Radiological Society. “We’re already down to bare bones. They’ve already trimmed the fat. We’ve now basically taken local imaging specialists out of the loop and you’re substituting paid consultants who are incentivized to deny claims. You’ve effectively destroyed the patient-physician relationship and this, in effect, rations health care. What’s the point of having a relationship with your doctor if the ultimate decisions are made by strangers thousands of miles away?”