Over the past few months, Austin-based breast reconstruction surgeon Elisabeth Potter, MD,
has become notable for her social media videos giving insight into the real-world interactions of physicians with health insurance companies. Potter has highlighted the prior authorization process and even posted a video of her phone call with a fellow physician serving as a peer-to-peer (P2P) reviewer for a large insurance company. The P2P reviewing physician states two things on this call that stand out: (1) they are not a breast reconstruction surgeon (and therefore not intimately familiar with the nerve-sparing mastectomy at question that was meant to preserve sensation), and (2) they are bound by company policy to not reveal their name (ostensibly for security reasons).
There are reasonable economic arguments for some level of prior authorization being a mechanism for reducing low-value care and therefore ensuring healthcare dollars are spent prudently. However, this phone call -- and many other documented instances of the challenges physicians face in overcoming prior authorization burdens -- raises important questions: is it ethical for physicians to actively participate in denials of medical care? Or could an argument instead be made that they have a moral imperative to do so?
The American Medical Association (AMA)'s Principles of Medical Ethics explicitly state, "A physician shall support access to medical care for all people." This presumably means that the ethical physician has a responsibility to ensure that any care in a patient's best interest that can be provided, is provided. These AMA principles suggest that physicians shouldn't act as P2P reviewers. In another framework, Tom Beauchamp, PhD, and James Childress's, PhD, famous 1979 Four Principles (of bioethics) reason that the ethical physician has respect for patient autonomy, is non-maleficent in their care, treats patients in a beneficial manner, and acts in a manner rooted in justice. Two of these principles are perhaps the most salient here. First, non-maleficence implies not engaging in activities that harm patients -- to most, denying care falls in that bucket. And second, beneficence implies only acting in the patient's best interest. These principles thus signify that physicians engaging in prior authorization denials are not acting in accord with bioethical principles.
But those are not the only principles at play here. Justice matters too.
"Justice" has myriad definitions. Indeed, philosophers across the centuries have devoted their lives to arriving at a single meaning. In this context, however, Beauchamp and Childress state that justice in medicine follows equality: "equals ought to be treated equally and unequals unequally." In other words, a medical system is just if two patients with the same medical circumstances receive the same care, without regard for extraneous factors -- presumably this would include ability to pay. However, they also argue that the "notion of distributive justice refers to fair, equitable, and appropriate distribution in society."
It is perhaps up to each individual physician how they interpret these definitions. Yet, no society is perfectly just. Ours has limited medical resources. Couldn't an argument be made that a physician serving as a P2P reviewer is upholding their responsibility to reduce low-value care? Following this logic, aren't P2P reviewers doing their part to ensure equitable "distribution [of medical resources] in society"?
What if instead of relying on the somewhat esoteric notion of justice, we conceptualize P2P reviewers as serving a harm reduction role? In other contexts -- for instance, opioid use disorder (OUD) -- harm reduction has grown in popularity as an evidence-based mechanism for limiting the most devastating consequences of an activity. In OUD, harm reduction may manifest as supervised injection facilities, where persons suffering from addiction can find sterile needles that limit transmission of serious diseases. In prior authorization, by serving as P2P reviewers couldn't one argue that physicians are reducing the harm that might come from a potentially amoral artificial intelligence platform taking the role instead?
Irrespective of arguments for or against physician participation in P2P review, we can all agree that the prior authorization process needs reform. Increasing prior authorization burdens are detracting from clinical time and causing burnout. Lack of appropriate clinical expertise among some P2P reviewers is leading to unclear conversations that frustrate care. Lack of personal liability for the downstream patient health outcomes caused by care denials, in consort with the anonymity many are afforded, gives P2P reviewers little accountability for their decisions. Continued prior authorization burdens on physicians with proven track records of high value care serve almost no purpose for scarce resource allocation, yet exacerbate consternation and inefficiency (some states, payors, and federal lawmakers have tried addressing this issue through "gold card" laws). Provider frustration has given rise to a growing industry of "profit enhancing middlemen" extracting funds from the healthcare system by attempting to reduce administrative burdens.
At the end of the day, our central question goes beyond whether physicians should serve as P2P reviewers. Rather, our crucial struggle is how to best align allocation of our society's limited resources with the fundamental aim of medicine: care for patients. There is a palpable tension between prudent spending of healthcare dollars and independent medical decisions. This challenge is unlikely to disappear any time soon. Yet, as we debate it, it is essential that reforms are grounded in ethical principles. Whether one views P2P reviewers as barriers to appropriate care or as necessary stewards of limited resources, our guiding principle must remain the same: decisions should serve patients' -- all patients' -- best interests. I refuse to let go of the hope that achieving a system that supports both fiscal responsibility and the profound doctor-patient relationship we so ardently cherish and seek is one day possible.
Manav Midha is an MD candidate at the Icahn School of Medicine at Mount Sinai and a researcher at the USC Schaeffer Center for Health Policy & Economics. All views are his own.
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