Prior Authorization & Health with Dr. Archelle Georgiou

Welcome & Introductions

Stanton Shanedling: Hello, everybody! Welcome to Health Chatter. Today's show is on prior authorization for health, because there's a lot of things that prior authorization links with. We've got a wonderful guest who's actually been on Health Chatter before, and we'll get to her in just a second.

We've got a great crew. I always like to recognize them: Maddy Levine-Wolf, Erin Collins, Deondra Howard, Sheridan Nygard, and Matthew Campbell are absolutely second to none to help us get these shows out to you, the listening audience. Clarence Jones is my partner in putting these shows together. He and HueMan Partnership... first of all, Clarence has a colleague, and Hugh Man Partnership is a sponsor for our shows. Dr. Barry Baines provides great medical insight for our shows, and so everybody is with us today.

HueMan Partnership, like I said, is our sponsor. You can check them out at Hue, H-U-Eman PartnershipAlliance.org. Great community health organization, do wonderful, wonderful things in the community. Thank you to them. You can also check us out at healthchatterpodcast.com for all the shows that we've done. Also, you can read transcripts and you can put in questions if you have them, so check us out there as well.

Today we have a complicated subject that we're going to be looking at: prior authorization. We've got a wonderful guest who's actually been on Health Chatter before, Dr. Archelle Georgiou. Actually, you know, she has an illustrious career. I mean, and I've known Archelle for quite a... quite a long time. I've always been struck by the creativity that Archelle brings to health, and also through communication. She's been really, really great. She's been a past health officer at Starkey, responsible for Starkey Hearing, and we actually had you on the show for that. Yes, we did. Right? Nationally recognized physician, author—she's written a great book—medical executive, and health reporter. She's the medical advisor, health advisor for KSTP Television in Minneapolis, St. Paul here.

I knew her first when she was the medical officer at United Health Group back in the late 90s and early 2000s. She has her medical degree from Johns Hopkins, and she also has her own podcast! Imagine that! As a great communicator: "Speak Up For Your Health," and I highly recommend that. It's a great show, very interesting subjects that she brings into that conversation, so check all that out. So, Archelle, thank you, thank you, thank you for being with us once again to talk about prior authorization.

Defining Prior Authorization and Its Intent

Archelle Georgiou: Thank you for having me, it's my favorite topic.

Stanton Shanedling: Is it really?

Archelle Georgiou: Absolutely it is.

Stanton Shanedling: Of all of these things. Well, she recently came out with an article on prior authorization that a lot of people have read and have reacted to. As soon as I got it, I read it, and I'm saying, "Yes, yes, yes, yes," you know, to everything that she was putting out there. But, alright, so let's first start out so we get everybody on the same wavelength here. First and foremost, for our audience, what exactly is prior authorization as it relates to health?

Archelle Georgiou: So, prior authorization is a concept that started when managed care became a thing in the 1970s and 80s. It's a process whereby the intent is that the health plan doesn't pay for unnecessary procedures or services, because that costs money. And the hope is that simultaneously, if the health plan avoids paying for those, the patient avoids having unnecessary services. So, in its intent, prior authorization is meant to improve patient care and decrease costs.

What happens is that if an individual goes to their doctor and needs something like an MRI, any inpatient care, a surgery, or an expensive medication—every health plan has its own list of services that require prior authorization—but before the patient receives that service, it has to go to the health plan. It goes through their clinical medical management staff, and then you and your doctor need to receive an approval for that service before it can be done, or else it won't be paid for at all. So that's how prior auth works.

Friction, Delay, and Patient Burden

Stanton Shanedling: Alright, so let me ask you something. You know, my sister, for instance, she's got an asthma medication that every year she's gotta get prior authorization for it, even though she carries the same health plan every year. And she's... you know, so it's gotten to the point where, and I've heard this from many people, where prior authorization links to aggravation. Especially for the patients.

Archelle Georgiou: Well, and that's really who suffers in this equation. Prior authorization, as I said earlier, in its intent, you know, intuitively that sort of makes sense. But the way that it is administered and executed has turned into so much friction for doctors, for patients, for everyone in the healthcare delivery system. But at the end of the day, the person who suffers from the delays in care, from the denied care, and all of, you know, what transpires out of that is the patient. And that's why it's my favorite topic, because this needs to get addressed.

Stanton Shanedling: And you addressed it. You addressed it when you were at UnitedHealth Group, and...

Archelle Georgiou: I did. When I snapped.

Stanton Shanedling: You were ahead of the curve.

Archelle Georgiou: Sure. So, let me just take a step back, because I think the context is important. In the 1980s and 90s, we were seeing the same managed care backlash at that time as we see today. Today might be even greater intensity, but we certainly felt it back then.

When I was in private practice, I remember the straw that broke the camel's back. I had a patient who had an abnormal physical exam, she had an abnormal pap smear, and she needed to have an advanced procedure by a gynecologist called a colposcopy. He knew it, I knew it, there was no question she needed it, and the health insurer denied it because they said that it didn't meet their criteria.

I was so upset with that, because it was getting in the way of her care, that I called the gynecologist and told them that if they didn't pay it, I would just pay it out of my own pocket. He did do the procedure, and she ended up having invasive uterine cancer. I just talked to her 2 years ago—this is 20 years later—and she's still alive and credits that advocacy for her being alive today. So, let's talk about where this passion started.

Stanton Shanedling: Yeah. Fast forward.

Archelle Georgiou: I went to UnitedHealth Group and was in the corporate office. When we were called together, me and my small team, to address how we would look for medical cost savings because of a financial situation at the time in 1999, our strategy was not to do more prior authorization and denials. Our strategy was to pull away from medical necessity denials, reallocate those resources to coordinating care, and that way, we would decrease the amount of fragmentation that people were experiencing, which drives cost.

Then, in the interim, have happier, healthier patients, much less friction with providers and patients, and frankly, the entire health plan staff, when we implemented this, loved what they were doing. They were so proud of what they were contributing to the actual care of patients by doing care coordination rather than denial care.

Stanton Shanedling: You know, and I remember that. I remember...

Archelle Georgiou: It was a big deal. It was a very big story in the United States, across the country. It wasn't just Minneapolis, yes.

Stanton Shanedling: And you know what? What I realized back then was, it decreased stress overall! I mean, if you're trying to address health, you don't want people who are sick or who need care to have another stressor to get their care. So, anyway, you were ahead of the... ahead of the curve for that.

Archelle Georgiou: Well, the person that was ahead of the curve was the CEO of the company, Dr. Bill McGuire, who was a physician himself and a very good businessman. It was his courage that, you know, enabled the fact that the entire business, all of UnitedHealth Group, went in this direction. We did a 4-month pilot, he saw the results, he said, "Take it nationally across every patient and every division." Wall Street asked us a lot of questions about the financial savviness of that move, and he had a lot of courage in allowing the company to move in that direction.

Historical Context and the Escalation of Barriers

Stanton Shanedling: So, Clarence, tell me, you run into this at all?

Clarence: You know what, I do. I recently had an experience where, fortunately, it was approved, but I think the thing for me is, when did this become a real barrier? Because for me, I know that when we start taking a look at the data, and you hear these stories in the newspapers and things like that, it's really creating a huge issue for a lot of people, both for the companies and for the individuals. When did this really become a barrier? What was the breaking point from that wonderful scenario that you originally gave?

Archelle Georgiou: Well, prior authorization's been a barrier and has caused friction for some time, and that was the root cause of the friction and the backlash that we saw in the 80s and 90s, which is what we addressed back then. It's been a barrier ever since. In UnitedHealth Group, just to address that, we eliminated this prior authorization review in 1999. It was completely absent from the company until about 2007, and it has slowly increased back to where it was since that time. In probably many or most other managed care companies, there's been prior authorization in place that causes friction.

It's become more a source of friction with the fact that health plans have expanded the number of items that need prior authorization. It's hard to get the counts on how many things needed to get a PA back then versus now, but in my research, it's somewhere in the 1,000 to 2,000 range of services. It used to be, in my day, 60, right? So, think about how prior auth requirements have expanded.

The other thing that has happened is that, with technology, it is much less expensive for a health plan to process each prior auth that they receive from an administrative standpoint. So it went from about—I'm in the ballpark with the numbers—about $25 for a health plan, down to 5 cents to 50 cents, right? So, it was so much less expensive for health plans to process these, they could afford to expand the list. It didn't become less expensive for clinicians to submit these prior authorizations, and so there's huge asymmetry in what it costs the provider and the payer, and here we are today with outrage over how disruptive it is.

Clinical Evidence, Transparency, and Financial Realities

Stanton Shanedling: Alright, Barry. You're our... you're our physician here.

Barry Baines: No, I got a partner as the guest on the show, are you kidding me? Yeah, right.

Stanton Shanedling: And I know you have some thoughts on this, you know, based on...

Barry Baines: Yeah, no, I do, because I think that, Archelle, you really captured it in the definition. It was one of these things that, clinically, it made some sense way back when it started, and the operationalization of that made it a mess, and it keeps getting worse and worse. Like you say, you go from 60 PAs, you know, prior authorizations, and we're in this state of prior authorization creep, where it just keeps like "The Blob," you know? It just keeps growing and growing and growing.

It causes such angst among patients, certainly, and among physicians, because it becomes this administrative nightmare, and a lot of it is not very transparent. Even... the thing that upsets me the most is that if this is a good idea, shouldn't there be some common clinical evidence base among all health plans for what would need a prior authorization? Like if someone wanted to take ivermectin for their COVID, you know, because there are a lot of crazy ideas out there, but there's also a lot of clinical evidence of things that are necessary and provide better health.

Right now, it's just all this administrative paperwork stuff that piles on the costs, not only financially but also emotionally on patients and physicians because they're stuck in this, and it makes it very, very difficult. The thing that was interesting, I think it was in the article that looked at some of the... with you finally getting your hands on some data, looking at health plans—the level of these denials that get overturned when it goes to a review committee is really more than 50%. I mean, you know, once you go through the process.

But what a lot of plans depend on—and again, I wonder about the data between for-profit and not-for-profit health plans, and I don't have access to the data, so I just wonder if you're able to get that to do some comparisons—but within that, it's like, to make money, you depend on people not appealing the denial.

Archelle Georgiou: Absolutely, absolutely.

Barry Baines: Absolutely, and just to put some... and I think it was like 100 million? I mean, it's a big number that flows to the bottom line in for-profit health plans, particularly, because you depend on people not fighting it, not speaking up, because it takes your time, you know? It takes time, and it takes effort, and you don't have the expertise with it that the health plan presents.

But the thing that gets to me is, where is the body of evidence for why something would need to be prior off? I think with certain medications, things come up, more data and research kind of expand the use of it, and there's always this lag time. That's the other piece, and oftentimes health plans might be a little bit slow with adapting and adopting some of the clinical evidence base into their whole prior off process, which has become like this big machine.

Patient Anxiety and Delays in Care

Stanton Shanedling: Well, Archelle, let me ask you, you know, this aggravation quotient that I mentioned before? It seems to me that if you've never, as a patient, had to deal with prior authorization, then all of a sudden you have something that you need, and you need prior authorization for it, it's like... most patients will say, "Okay, where in the hell do I start? What do I do here?"

Archelle Georgiou: Sure, well, it's really the provider that's responsible for submitting for a prior authorization.

Stanton Shanedling: Correct.

Archelle Georgiou: For whatever list. And so, the responsibility for submitting the request is on the provider. Otherwise, if they provide that service and haven't gotten a PA, they're just not going to get paid, and the patient can't get balance billed. So, that's where it starts, is with the provider that's going to do the procedure.

But in the meantime, even though the responsibility for submitting it doesn't fall with the patient, think about the anxiety of the threat of, "Well, what if it doesn't get approved?" Right? That's very stressful for an individual. And then let's add into that that you've just gone to a clinician and they've said, "You need this surgery, this MRI, this next service," and now there's going to be a delay in care. Health plans have at least 7 days to turn around that request and give you a yes or a no.

But there's a caveat: seven days from the date that they decide that the prior authorization request has all of the elements in it—a clean submission. Well, maybe your doctor's office, you know, forgot to submit documentation A, B, or C, then you could be waiting a few weeks to get that approval or denial back. So think about the delays in care that occur that impact the patient as well. First they have stress, then they have delays.

There's a journal article that I'm happy to share that looked at 25 different studies of prior authorization—good studies—and demonstrated that there's an increased hospitalization rate, and for cancer patients, an increased mortality rate. So, we know that overall this process has the ability to impact quality of care.

Stanton Shanedling: And you know something, timing is crucial for some of these things. I mean, you know... Go ahead, Clarence.

Clarence: Yeah. Archelle, you talked about the patient that applied for it needing a service and she was denied. I, as a community member, I want to come at it from a community perspective. I think about the numbers of deaths, you know, increased mortality that happens as a result of this. Are there any numbers about how this has affected or increased deaths in this work?

Archelle Georgiou: Yes. There's one study—I don't have the numbers at my fingertips, but it was included in this systematic review of prior authorization studies, happy to send it to you—but it showed that specifically in cancer patients, the delays in care were linked to increased mortality.

Clarence: And increased costs, and increased other kind of factors as well. I mean, just going through that process.

Archelle Georgiou: Well, you know, this study specifically looked at the care delivery component, as well as hospitalization. So, it looked at a number of different points in the system.

Clarence: Okay, thank you.

Call to Action: Access to Data

Stanton Shanedling: So, Archelle, I've got a question for you. All right, okay, your background research on this and the most recent articles you've written were great. And so my follow-up to that is, okay, how do you affect change? How do we get something changed as it relates to prior authorization across the myriad of health plans that we have?

Archelle Georgiou: Sure. So, my call to action with all of this work that I'm doing—and you'll continue to see more things published, so there was a MarketWatch Wall Street Journal article that was published yesterday that I'm happy to share with you—I'm trying to be very focused in the call to action, which is that we can't really design a better solution until we have better visibility to the data.

Let me just put some context around that. CMS made great progress in requiring plans for their exchange plans, Medicare and Medicaid, to submit this data that allowed me to do this analysis. Wonderful first step.

However, the data is hidden across payers' websites. Sometimes it's under provider tools, sometimes it's under compliance, sometimes it's called PA metrics, sometimes it's called interoperability metrics. I mean, I have been searching for hours and hours to put an analysis together of just 6 Medicare Advantage plans. There are thousands of plans across the country.

And so, I believe that the first next step to design a solution is to start with data. Therefore, who has the resources other than CMS and the power to pull all the data together? So, my immediate call to action: I hope that CMS can require that all of these submissions get uploaded in a specific, simple file format to one location. CMS can normalize the data and then publish it in something that is accessible to the public, accessible to policymakers, accessible to researchers, so that then we can begin to see the scope of the problem. I don't think that's an unreasonable ask. Let's start there.

Stanton Shanedling: Okay, and who has the power to decide to move forward in that way? Who?

Archelle Georgiou: I don't even know that that's legislation that's required. I believe that CMS has the power to say, "You're our contractors," because they pay federal monies. And so, you all published this, which was required by law to be published by March 31st of 2026. Yeah. But they didn't require a file format, and they didn't explicitly state where it needed to be placed on a website. So, it exists. I'm gonna assume that all plans want to comply with CMS. Now, all they have to say—this is not law, all they have to say—is, "Submit that to CMS."

Stanton Shanedling: Yeah.

Archelle Georgiou: No new laws, no new policies.

Stanton Shanedling: Alright, so...

Archelle Georgiou: I mean, as a public health person, does that sound like something that's achievable?

Stanton Shanedling: You know, I hedge the answer on that one, okay? And the reason why is everything of late seems to take longer and becomes more complicated as we go. And the more players that you have involved with it, also... All right, I've got other questions. Aaron, I know you're chomping at the bit, okay?

Living with Chronic Illness: Erin's Story

Erin I really am. Archelle, I'm not sure if you know this, but I have type 1 diabetes. There is no cure for type 1 diabetes.

Archelle Georgiou: I know that.

Erin: I can't get rid of my type 1 diabetes, and every year, I have to submit prior authorizations for my continuous glucose monitors and my insulin pump supplies. Now, are these required to manage and navigate my chronic disease? They're not, but compared to not having them, it is a world of a difference and an experience in life. And I just... I hear your frustration on some of the, like, preventative pieces of it, but there's a second half to it where my disease is never going away, but somehow I have to submit a prior authorization every year for this. I know that this is a problem that is across the board with lots of other chronic diseases.

And so, my question kind of stems a little bit from Stan's question about a call to action, but it's also kind of taking the next step to that. With the mindset of, yes, there are aspects of prior authorization that are helpful and the intent to be good was there, do you have a more patient-centered prior authorization approach in mind? Something to replace the current system that we're doing, or are you more thinking in a mindset of, "Let's get the data out there and publicized for wide audiences to view?" I'm curious what your thoughts are on that.

Archelle Georgiou: Yeah, so, so many things that I could say about this. First of all, let me just say that back in 1999, which was a long time ago, we completely eliminated medical necessity review. We stopped it and replaced it with a system of care where everybody was reassigned to a new job that coordinated care. We did it back then, we had good results, so I'm assuming that with the right leadership and the right tools and resources, we could redo that.

I've also learned that we're not going to have such... it was a revolutionary change. I don't think that's going to happen today, because no revolutionary changes are happening. So, yes, let's start with the data. But the other thing that I think is important to state here, Erin, is that prior authorization isn't necessarily a bad thing to do if it's not generating stress and delays, right? So, let's go back to your situation.

Of course you need insulin, and you will need it every day for the rest of your life, unless some miracle happens—and hopefully it will. But, if the value of a prior authorization between you and your insurance company is that they can validate you're taking it, you've refilled it on a regular amount of time... If they don't get in the way of you getting your insulin, but simply want to know how many refills you had, what did it cost, what pharmacy did you use? There's a whole bunch of reasons that are of value for you to inform them, or for them to be informed, about what you're taking.

Where I believe there needs to be change is when that process results in delays to you. So, I think there's something in between. We were notified of a lot of medical care even back in 1999—we were notified of hospital admissions, we were notified of surgeries. We didn't say no. We used that moment to try to understand, how can we help you be healthier? So, yes, that would be how I would replace how we do that.

Single Payer vs. Current System Realities

Stanton Shanedling: Oh, sorry, Archelle, you know...

Archelle Georgiou: You sound exasperated.

Stanton Shanedling: Well, it's an exasperating subject! I mean, we've been dealing with this for God knows how long. So, alright. Single payer. Would that have a major impact on this?

Archelle Georgiou: Well, let's talk about that. We have a single payer for seniors, it's called Medicare. Do you agree?

Stanton Shanedling: Correct, correct.

Archelle Georgiou: Perfect. We have a single-payer system called Medicare, and Medicare Advantage has resulted in the rates that you see. So, it is within a single-payer system that I analyzed the results where we're seeing 10% denial rates, 66% overturn rates. So, no, I don't think the single payer is a solution to this problem. In addition, I will remind you that even in traditional Medicare, not Medicare Advantage, they just introduced the WISER model to bring prior authorization processes into traditional Medicare in 6 states. It's not going well. It just started January 1st of this year. It's not going well.

Stanton Shanedling: Hmm. Okay, so how about the idea that yesterday there was no reason to have prior authorization for whatever, and today there is? Do we see that happening? It's like today, or yesterday, you didn't need prior authorization for this medication. Today, you do. Those changes.

Archelle Georgiou: Well, I mean, we see that all of the time because the health plan changes their criteria. You know, in particular, we see those sorts of changes with pharmaceuticals because they're always negotiating with their pharmacy benefit manager, and depending on which drugs are getting the rebates and which ones are in various tiers, that's probably where you'll have the most chaos in terms of, "I didn't need it last month, but I do need it this month."

The Role of Technology and AI

Stanton Shanedling: Gotcha. All right, and then... I know everybody's chomping at the bit here, so here's the other thing. What about artificial intelligence? How would that affect this, as far as maybe quickly or more effectively getting prior authorization answers for patients and providers?

Archelle Georgiou: You know, you could look at it from both sides, Stan. You could see it as being a way to automate and accelerate the process. And I can see that happening for approvals, and I'm very hopeful that that's gonna happen. It certainly decreases the administrative cost on the payer's end. But as we've also seen, that has allowed them to expand the number of services they require prior authorization for. But it could accelerate the turnaround time; that would be ideal.

But the issue is when there are services that are going to be denied. That must go through a human and a clinician, because it's the individual circumstances that have to be taken into account in order to issue that denial. And so, it's those delays that I'm worried about.

Stanton Shanedling: Hmm.

Archelle Georgiou: I will also say, I know that the WISER program is just, at this point, 4 months old, but the whole pilot is using AI and we're seeing higher denial rates, longer turnaround times, and higher appeal turnover rates. So, at least in this short-term experiment that CMS is doing, the results are not good at this point.

Clarence: Hmm...

The AI Arms Race and "Gold-Carding"

Stanton Shanedling: Alright, Barry, you're up.

Barry Baines: One thing to pile on with the AI thing: actually this morning, going around the lake with a couple of my friends—one of whom is very involved in AI—I told him about prior authorization. He's not medical, but he said, "Well, you know, providers are using AI to sort of try and come up with the best way that's going to get the immediate approval for their patient, and health plans are using AI to dig into why... how they could build in the denials, or additional delays, or whatever it is." So you have AIs on opposing sides of the toothpaste test, so to speak, trying to out-game the other. I can't imagine how the outcome of that is going to be good for... you know, necessarily good for patients. So that's one thing.

And then the other thing, because I wasn't aware of it, but from the great research we had, this idea of gold-carding physicians who just... so let's see, you know, Erin, I'll just use your case. Your physician sends it in, and you get approved. Well, you know, after 10 years of that, maybe your physician gets the gold card and they just send in the prescription for what you need, and it just passes right through because it's, you know, Dr. DoGood really has a good track record with their diabetes patients and stuff like that. But I don't know anything about this gold carding and how this might impact, and I'm wondering...

Archelle Georgiou: Sure. So, Barry, that has promise as well. Some states have put regulations in place to require it. You know, I'm not trying to knock all innovation. I think that it has promise. But let's think about the patients that are going to the doctor that's not gold-carded. Because not all patients go to gold-card physicians. So, what about their care? What about their delays in care? And I'm concerned about that.

Cost vs. Quality of Care

Stanton Shanedling: So here's... what about... what's come to mind for me are new procedures and new medications. Are they automatically on the prior authorization list?

Archelle Georgiou: Depends on the cost.

Stanton Shanedling: Really? So it just gets down to cost for that, then.

Archelle Georgiou: Well, I don't know what the decision-making process is in every health plan, but it's fair to say that one of the thresholds is going to be cost, you know, because it's a cost-benefit analysis of how much effort are you putting into the review.

Stanton Shanedling: As opposed to what's needed for the patient.

Archelle Georgiou: Oh, let's be really clear. This is not a quality of care improvement program. Let's put aside that prior authorization improves quality of care. Let me give you the best argument to defend my statement, which is: has anybody here been denied care? Anybody on the call?

Stanton Shanedling: Oh, yeah. Wait, wait, wait, Erin has, Erin has.

Archelle Georgiou: Erin, what was denied?

Erin: I wasn't allowed to get a continuous glucose monitor until being 6 months into my diagnosis with diabetes.

Archelle Georgiou: Okay, so you were denied that. And when they denied it, did the health plan... so they went through the process of saying no. Did the health plan get involved in finding an effective way for you to have a stable management of your diabetes during that 6-month period? Did they get involved with you to help you coordinate your care?

Erin: Not that... not that I can really remember. This is now almost 10 years ago, but we put in immediately for a request for a continuous glucose monitor. For those listening that don't know what that is, it takes your blood sugar every 5 minutes, and you basically get visualization of what your blood sugar is 24-7. Game changer. And you don't have to prick your fingers.

Their justification at the time was that anybody who had a new diagnosis of type 1 diabetes should feel comfortable with managing their blood sugar, pricking their finger, and using multiple daily injections before getting on an insulin pump or a continuous glucose monitor, in the event that you cannot utilize either of those.

So, for 6 months on my plan, I was required to do multiple daily injections, or MDI, and finger pricks. And even then, finger pricks still weren't covered at 100% out of our plan. I remember my first insulin prescription was like $1,500, and every time I went to go get test strips, it was about $60. So, definitely not working with us to make it cheaper or more accessible in a way.

Archelle Georgiou: So, Erin, that's so interesting that that's the rationale that they gave you, because that sounds like something your doctor would want to weigh into with you, rather than your health plan. That's a preference as to whether or not you want to learn how to prick your finger and how to have that experience. And I don't say this lightly, but that, to me, is an example... you know, that's pretty close to practicing medicine. And that's dangerous. That's really dangerous. If they say that our guidelines don't approve it because you don't meet them for a guideline reason, that's a little different. But to give you that rationale, that sounds...

Erin: It's very interesting. I constantly think about—and I work in the world of type 1 diabetes now, so I'm constantly hearing stories about things that have gone wrong, or horror stories and things—but I constantly think about, if I ever have a lapse between supplies or have a delay in getting supplies, that could be absolutely detrimental to...

Archelle Georgiou: Life-threatening.

Erin: Not to mention, it could result in a hospitalization for DKA, which in the end probably costs more than the entire conversation to begin with. And so it's just such an interesting thing to me that, especially for type 1 diabetes, we're still battling through some of these administrative processes. Your example about cancer screening, too, just from a public health lens, is just... it is so powerful, and if people aren't able to see the problem within that, I don't know what else to say. It is so challenging. First of all, this has been a lovely episode, too. I'm just... I'm eating it all up. This is really great.

Archelle Georgiou: Good.

Erin: Thank you for the public...

Archelle Georgiou: Well, I think the more that we can amplify as a community that this is an issue that affects patient care, let's at least take steps toward making it a more rational process that doesn't cause delays and poor health outcomes. You know, one of the things that I realized recently is that if there's a device—if Medtronic, such a great company in our community—if Medtronic notices a signal in the feedback that they're getting from a pacemaker or a device where something's not firing right, maybe there is an adverse effect on patient care, they will reach a low threshold for reporting to the FDA. They might pause using any more of those. They could put a warning box on it; we've seen that with some products. Sometimes they take things off the market when there's any concern about patient care.

Here, we have data, published studies that show that prior authorization causes delays in patient care and poorer health outcomes, and we're tolerating it with the promise that the payers are going to try to improve it through this voluntary commitment by 2027 or 2028. We expect quality in the future; we expect quality now.

Stanton Shanedling: Exactly.

Archelle Georgiou: So, if we have it, it needs to meet a certain threshold of quality, of turnaround time, of process improvement. Now, not in 2 years.

Real-Life Impacts: Surgical Schedules and Personal Stories

Stanton Shanedling: You know, it's interesting, a friend of mine recently had to go through all of this rigmarole. He had to have a procedure, a surgical procedure, and so he was advised to schedule the procedure, right? Because getting on a surgical schedule can take some time, okay? So they were basically dealing with coordinating a surgical procedure and timing with the prior authorization.

Well, it got up to the point—it was actually two days before he was supposed to go in for his surgery—and the prior authorization still hadn't been addressed yet. So you can imagine the angst, okay? So he and his physician finally said, "Let's do the procedure. Let's go ahead. Let's just do the procedure." And they did that. The next day after he had his surgery, it was authorized. Yeah. I mean, so that... creates aggravation.

Archelle Georgiou: Very much. Let me tell you a story. It's actually at the top of my newest article. I know how to work this system, right? So my husband...

Stanton Shanedling: Yeah, your husband went through this.

Archelle Georgiou: Osteoporosis—and yes, men can get osteoporosis, about 25% of men after the age of 50 get osteoporosis. He was told by his endocrinologist that he needed a special injection. He's been on many medications; his bone density still is declining and going in the wrong direction. He was told in June that he needed this injection. And then, after, I think I counted 10 plus hours of phone calls for the prior auth, 3 subsequent submissions of data, it did not get approved until January. So, like, 6, 7 months later.

Stanton Shanedling: I remember this.

Archelle Georgiou: Yay. He had bone loss.

Stanton Shanedling: Right? Yeah.

Archelle Georgiou: But here's what was really aggravating: first of all, it took 6 or 7 months, but because it got approved in January rather than December, our deductible renewed, and we had to pay the $2,000 for that. And guess what? The health plan didn't have to pay out $2,000 if it had been approved even a month earlier. I mean, it's aggravating!

Stanton Shanedling: Yes, yes! So you know, I mean, it's real life.

Archelle Georgiou: If I can't work the system, think about how challenging it is for others.

Stanton Shanedling: Correct. And think about the elderly.

Archelle Georgiou: Ugh.

Stanton Shanedling: Who have no clue how to... the technology involved in all of it. And they just say, "Whatever." You know, it gets to that point where you throw up your hands and say, "Whatever."

Archelle Georgiou: So, back to the question of AI, you know, one of the other responses to that is that we have such a broken system that's causing so much chaos and frustration, what we're doing is scaling it. We're scaling a fragmented, frustrating system. That worries me about using AI.

Key Takeaways and Advice for Patients

Stanton Shanedling: Yeah, yeah. Well, I'll tell ya, I really, really applaud your insights, and actually your professionalism as it relates to this subject. I'm gonna ask you this, what's the key... at this point, you know, given where you are with your writings and everything, what's the key takeaway for you right now?

Archelle Georgiou: Well, the key takeaway... there's two. One is what every single listener should know, which is that if you receive a denial, you should appeal it. The steps are easy. It's designed to have it seem like it's hard, but it's easy. Make sure that you do it all in writing. Get a copy of the denial letter itself, a physical copy—I mean, it could be digital, physical, but get a copy of the denial. Make sure that it includes exactly why your service was denied. Write your own appeal letter and be crisp in responding to the reason for the denial and why it should be overturned.

Keep close track of timelines, because they're on the clock, and you could sometimes have it overturned just because they've exceeded a time frame. And make sure that your doctor files an appeal also. Do not delegate this responsibility to your doctor. They should submit one, and you should submit one. And if you do believe that you should receive approval for a service and you're not after the appeal, contact the regulatory agency for insurance companies and the attorneys general. I just escalate very quickly.

Final Thoughts & Wrap-Up

Stanton Shanedling: Yeah, yeah. Really good point. Alright, Barry. Last thoughts from you.

Barry Baines: Yeah, I just want to echo and emphasize all the things that Archelle just now told people. Do that as fast as you can. This is a great conversation, and for me, right now with where things are at in the current government administration, I think the idea of anything that's going to be favorable to dealing with this kind of issue... the probability is probably low when you look at things, just in general, how Medicare and Medicaid are viewed within this current administration.

That said, I think having people to be knowledgeable about this, and to be speaking up and practicing advocacy, really is an opportunity for both patients and physicians to work collaboratively again, with the common goal of trying to be as healthy as you can and moving this forward. This really, by and large, creates an impediment to improved health. And so, like many of the topics that we've been talking about here, we have to just stay on it. We have to stay on it and keep pushing forward. So that's just my quick impressions. This is, again, a great conversation, and Archelle, it was great to meet you.

Archelle Georgiou: Nice to meet you as well.

Barry Baines: Sort of in... sort of in person.

Stanton Shanedling: Clarence, what do you think, from a community perspective? Are you there? Clarence might be off, I know he had a busy day today. All right, Erin! 

Erin : And I seriously enjoyed the last hour so much. This was a great episode to be able to be in person for, and I greatly appreciate all the work you're doing, especially in the type 1 diabetes space. Advocacy is so powerful and so important—self-advocacy, advocacy to legislators, local and national. I just feel like prior authorizations can kind of be looped into that theme of advocating for yourself, advocating for the system, and I'm just so excited to see where this goes. I really appreciate you for all your hard work on this. It's great.

Archelle Georgiou: I absolutely would love to sort of amplify with all of your voices all of this, so if we can work together in the future, that would be great.

Clarence: Well, Stan, I'm back. I am back, I am back. Archelle, I tell you, I feel like I could be an expert right now in giving tips for responding to a denial letter, okay?

Archelle Georgiou: Good!

Clarence: Yeah, I... and I'm hoping that we write these things down. But very seriously, I think that, as Erin said, it's been a phenomenal show, and for someone who was not aware of this subject as much as I needed to be, thank you. So, that's all I gotta say, Stan. Thank you again, Archelle, and thank you for being on our show.

Archelle Georgiou: Thank you.

Stanton Shanedling: For our listening audience, all I can say is, as it relates to prior authorization: take a deep breath. You know, I've been into yoga lately. Take a deep breath, just keep it calm, and you can get through this. But your advice, Archelle, is second to none, and I really, really gratefully appreciate it. Hopefully it provides some clarity for our listening audience as well. So thank you, thank you for the work you do. I really...

Archelle Georgiou: Oh my goodness, well, thank you for letting me have this opportunity. If I could ask, if it works for any or all of you, I would love to have you repost that last post. I know that got the attention of the first one, but the second one is equally important. The MarketWatch article that I referenced, which is on a link, has all of those steps of how to deal with a denial right in the article, and so if you could repost that and amplify it, it's so greatly appreciated.

Stanton Shanedling: We'll add that to our background that we put on our website. And if there's other articles or insights that you want us to include, just send them off.

Archelle Georgiou: Perfect. Perfect. I think I sent you the one last night, a link to that.

Stanton Shanedling: Yes, you did.

Archelle Georgiou: And then if you could do something on LinkedIn, that would be superb.

Stanton Shanedling: Perfect, perfect. So for upcoming shows, guys, we've got great episodes coming up. We've got a show on addiction and the Grateful Foundation, which is really interesting. Also, we're going to be addressing disabilities—and we've addressed disabilities before, but this time we're going to be focusing on it from a research, policy, and data angle, with a wonderful guest that we'll have. So, great shows coming up. Everybody out in the listening audience, keep health chatting away!