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Choosing a career as chief medical officer at a health technology startup
How did your career pathway lead you to working at a health tech startup?
I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).
What do you do as CMO?
There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:
- Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
- Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction.
- Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
- Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
- Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
- Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.
What do you enjoy most about working at a startup?
The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus.
What do you find most challenging about working at a startup?
One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience.
What are the ways that GIs can get involved in startups?
Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:
- This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
- Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
- Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).
- Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently.
How would a fellow or early-career GI who is interested in startups pursue this career pathway?
The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.
What if I want to learn more about the health technology startup experience?
The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.
Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.
How did your career pathway lead you to working at a health tech startup?
I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).
What do you do as CMO?
There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:
- Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
- Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction.
- Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
- Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
- Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
- Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.
What do you enjoy most about working at a startup?
The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus.
What do you find most challenging about working at a startup?
One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience.
What are the ways that GIs can get involved in startups?
Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:
- This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
- Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
- Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).
- Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently.
How would a fellow or early-career GI who is interested in startups pursue this career pathway?
The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.
What if I want to learn more about the health technology startup experience?
The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.
Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.
How did your career pathway lead you to working at a health tech startup?
I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).
What do you do as CMO?
There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:
- Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
- Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction.
- Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
- Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
- Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
- Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.
What do you enjoy most about working at a startup?
The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus.
What do you find most challenging about working at a startup?
One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience.
What are the ways that GIs can get involved in startups?
Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:
- This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
- Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
- Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).
- Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently.
How would a fellow or early-career GI who is interested in startups pursue this career pathway?
The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.
What if I want to learn more about the health technology startup experience?
The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.
Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.
Prior authorization – a call to action
Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.
Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.
Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.
Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.
Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.
One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.
In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.
You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.
If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.
Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.
While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.
Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Tihs story was updated on July 29, 2019.
Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.
Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.
Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.
Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.
Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.
One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.
In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.
You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.
If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.
Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.
While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.
Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Tihs story was updated on July 29, 2019.
Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.
Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.
Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.
Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.
Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.
One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.
In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.
You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.
If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.
Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.
While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.
Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Tihs story was updated on July 29, 2019.