In a handful of cases, health insurers reversed denials after physicians or patients posted complaints on social media
Prior authorization requirements by health insurers have long been a thorn in the side of medical laboratories, as well as physicians. But now, doctors and patients are employing a new tactic against the practice—turning to social media to shame payers into reversing denials, according to KFF Health News (formerly Kaiser Health News).
Genetic testing lab companies are quite familiar with prior authorization problems. They see a significant number of their genetic test requests fail to obtain a prior authorization. Thus, if the lab performs the test, the payer will likely not reimburse, leaving the lab to bill the patient for 100% of the test price, commonly $1,000 to $5,000. Then, an irate patient typically calls the doctor to complain about the huge out-of-pocket cost.
“There are times when you simply must call out wrongdoings,” she wrote in an Instagram post, according to the outlet. “This is one of those times.”
In response, an “escalation specialist” from BCBSIL contacted her but was unable to help. Then, after KFF Health News reached out, Nix discovered on her own that $36,000 in outstanding claims were marked “paid.”
“No one from the company had contacted her to explain why or what had changed,” KFF reported. “[Nix] also said she was informed by her hospital that the insurer will no longer require her to obtain prior authorization before her infusions, which she restarted in July.”
“I think we’re on the precipice of really improving the environment for prior authorization,” said Todd Askew, Senior Vice President, Advocacy, for the American Medical Association, in an AMA Advocacy Update. If this was to happen, it would be welcome news for clinical laboratories and anatomic pathology groups. (Photo copyright: Nashville Medical News.)
Physicians Also Take to Social Media to Complain about Denials
Two weeks later, he reported that the treatment was approved soon after the tweet. “When did Twitter become the preferred pathway for drug approval?” he wrote.
Eunice Stallman, MD, a psychiatrist from Boise, Idaho, complained on X (formerly Twitter) about Blue Cross of Idaho’s prior authorization denial of a brain cancer treatment for her nine-month-old daughter. “This is my daughter that you tried to deny care for,” she posted. “When a team of expert [doctors] recommend a treatment, your PharmD reviewers don’t get to deny her life-saving care for your profits.”
However, in this case, she posted her account after Blue Cross Idaho reversed the denial. She said she did this in part to prevent the payer from denying coverage for the drug in the future. “The power of the social media has been huge,” she told KFF Health News. The story noted that she joined X for the first time so she could share her story.
Affordable Care Act Loophole?
“We’re not going to get rid of prior authorization. Nobody is saying we should get rid of it entirely, but it needs to be right sized, it needs to be simplified, it needs to be less friction between the patient and accessing their benefits. And I think we’re on really good track to make some significant improvements in government programs, as well as in the private sector,” said Todd Askew, Senior Vice President, Advocacy, for the American Medical Association, in an AMA Advocacy Update.
However, KFF HealthNews reported that Kaye Pestaina, JD, a Kaiser Family Foundation VP and Co-Director of the group’s Program on Patient and Consumer Protections, noted that some “patient advocates and health policy experts” have questioned whether payers’ use of prior authorization denials may be a way to get around the Affordable Care Act’s prohibition against denial of coverage for preexisting conditions.
“They take in premiums and don’t pay claims,” family physician and healthcare consultant Linda Peeno, MD, told KFF Health News. “That’s how they make money. They just delay and delay and delay until you die. And you’re absolutely helpless as a patient.” Peeno was a medical reviewer for Humana in the 1980s and then became a whistleblower.
The issue became top-of-mind for genetic testing labs in 2017, when Anthem (now Elevance) and UnitedHealthcare established programs in which physicians needed prior authorization before the insurers would agree to pay for genetic tests.
Dark Daily’s sister publication The Dark Report covered this in “Two Largest Payers Start Lab Test Pre-Authorization.” We noted then that it was reasonable to assume that other health insurers would follow suit and institute their own programs to manage how physicians utilize genetic tests.
At least one large payer has made a move to reduce prior authorization in some cases. Effective Sept. 1, UnitedHealthcare began a phased approach to remove prior authorization requirements for hundreds of procedures, including more than 200 genetic tests under some commercial insurance plans.
However, a source close to the payer industry noted to Dark Daily that UnitedHealthcare has balked at paying hundreds of millions’ worth of genetic claims going back 24 months. The source indicated that genetic test labs are engaging attorneys to push their claims forward with the payer.
Is Complaining on Social Media an Effective Tactic?
A story in Harvard Business Review cited research suggesting that companies should avoid responding publicly to customer complaints on social media. Though public engagement may appear to be a good idea, “when companies responded publicly to negative tweets, researchers found that those companies experienced a drop in stock price and a reduction in brand image,” the authors wrote.
KFF Health News reported that the federal government is proposing reforms that would require some health plans “to provide more transparency about denials and to speed up their response times.” The changes, which would take effect in 2026, would apply to Medicaid, Medicare Advantage, and federal Health Insurance Marketplace plans, “but not employer-sponsored health plans.”
KFF also noted that some insurers are voluntarily revising prior authorization rules. And the American Medical Association reported in March that 30 states, including Arkansas, California, New Jersey, North Carolina, and Washington, are considering their own legislation to reform the practice. Some are modeled on legislation drafted by the AMA.
Though the states and the federal government are proposing regulations to address prior authorization complaints, reform will likely take time. Given Harvard Business Review’s suggestion to resist replying to negative customer complaints in social media, clinical labs—indeed, all healthcare providers—should carefully consider the full consequences of going to social media to describe issues they are having with health insurers.
It’s not just radiology. Gen Z residents will be matching in pathology and other specialties, and that means clinical laboratories should be ready to adapt their recruiting and training to Gen Z’s unique characteristics
It’s a big event in medical schools across the nation when it is time for residency programs to match residency candidates with first-year and second-year post-graduate training positions. But this year has a special twist because—for example in radiology—this is the first class of Generation Z (Gen Z) residency candidates to be matched with radiology residency programs.
In their abstract, the authors wrote, “This year, the radiology community will experience the beginning of a generational change by matching its first class of Generation Z residents. To best welcome and embrace the changing face of the radiology workforce, this Viewpoint highlights the values that this next generation will bring, how radiologists can improve the way they teach the next generation, and the positive impact that Generation Z will have on the specialty and the way radiologists care for patients.”
Members of Gen Z are now entering the workforce in large numbers. To recruit high-quality candidates from this generation, healthcare employers—including clinical laboratories and pathology practices—may have to adapt the way they interact with and train these individuals.
Gen Z is generally described as individuals who were born between 1995 and 2012. Also known as “Zoomers,” the demographic comprises approximately 25% of the current population of the United States. They are extremely diverse, tend to be very socially conscious, and can easily adapt to rapid changes in communications and education, according to the AJR paper.
Although the paper deals with radiology, this type of information can also be valuable to clinical laboratories as Gen Z pathologists are poised to enter clinical practice in growing numbers. This marks the beginning of the professional laboratory careers of Zoomers, while Millennials move up into higher levels of lab management, the oldest Gen Xers near retirement age, and Baby Boomers retire out of the profession.
“Gen Z employees bring unique values, expectations, and perspectives to their jobs,” said Paul McDonald (above), Senior Executive Director at staffing firm Robert Half in a news release. “They’ve grown up in economically turbulent times, and many of their characteristics and motivations reflect that.” Thus, clinical laboratories may have to develop methods for recruiting and training Gen Z staff that match the unique characteristics of Gen Z candidates. (Photo copyright: LinkedIn.)
Zoomers Like Digital and Artificial Intelligence Technology
One of the most unique aspects of Gen Z is that they have never lived in a world without the Internet and have little memory of life without smartphones. Zoomers grew up totally immersed in digital technology and tend to be comfortable using digital tools in their everyday life and in the workplace. They lean towards being very open to artificial intelligence (AI) and how it can assist humans in analysis and diagnostic methods.
“This group of professionals has grown up with technology available to them around the clock and is accustomed to constant learning,” said Paul McDonald, Senior Executive Director at staffing firm Robert Half in a news release. “Companies with a solid understanding of this generation’s values and preferences will be well prepared to create work environments that attract a new generation of employees and maximize their potential.”
According to the AJR paper, Zoomers learn best by doing, so employers should concentrate on interactive learning opportunities, such as simulations, virtual reality, and case-based methods for teaching the aspects of the job. They are likely to expect digital and blended resources as well as traditional approaches to learning their new job responsibilities.
The paper goes on to state that Gen Z members value diversity, equity, inclusivity, sustainability, civic engagement, and organizational transparency. Their social consciousness and diversity may yield a greater range of perspectives and problem-solving approaches which may bolster their sensitivity to patient-centered care.
“The oldest in Gen Z have already seen a recession and a war on terrorism. They’ve seen politics at its worst. And now they’ve seen a global pandemic and are about to see recession again,” said David Stillman, founder of GenGuru, a boutique management consulting firm that provides insights on how best to connect with Baby Boomers, Generation X, Millennials, and Gen Z, in an interview with the Society for Human Resource Management (SHRM). “They are survivors,” he added.
According to the SHRM, “Stillman says Millennials, who preceded Generation Z, were coddled by their parents. He maintains that Generation Z’s parents were more truthful, telling their offspring, ‘You’re going to have a really tough time out there, you have to work super hard,’ which he says created ‘the most competitive generation in the workforce since the Baby Boomers.’”
Gen Z Wants More than a Paycheck, They Want Purpose
The American Journal of Roentgenology paper also states that Gen Z members grew up in a rapidly changing world and tend to be resilient, adaptable, and flexible. They have experienced and witnessed many stressors and navigate these issues by focusing on mental health and a meaningful work-life balance. With respect to a profession, they are searching for more than just a paycheck, and they want a purposeful career where they feel a sense of belonging.
Increase information sharing and transparency to help alleviate fear and anxiety.
Incentivize them by showing them clear paths to career progression.
Make sure they know how their individual contributions matter to the organization.
Motivate them by giving them room for autonomy and experimentation.
Provide specific and constructive feedback.
Harness community and in-person interactions to boost professional collaborations.
Prioritize wellness and mental health.
“Be prepared to spend time with them face to face,” McDonald stated. “They want to be mentored and coached. If you coach them, you’re going to retain them.”
Preparing to Attract Gen Z to Clinical Laboratories
As Generation Z comes of age, more of them will be working in the medical professions. Clinical laboratories and anatomic pathology groups would be well advised to prepare their businesses by adjusting leadership, adapting recruiting efforts, and shifting marketing to attract Zoomers and remain relevant and successful in the future.
Although sweeping statements about individual generations may be limiting, understanding their unique insights, values, and backgrounds can be helpful in the workplace. With a large amount of Gen Z workers now transitioning from college into careers, it will be beneficial for clinical laboratory managers to recognize their unique characteristics to recruit and maintain talented workers more effectively.
Despite high-hopes and much fanfare, the collaboration failed to transform healthcare and lower healthcare costs for everyday Americans as many anticipated it would
Another anticipated “disruptor” to today’s healthcare market is closing its doors. Three years ago, in 2018, Amazon (NASDAQ:AMZN), Berkshire Hathaway (NYSE:BRK.A), and JPMorgan Chase (NYSE:JPM) announced a joint venture to enter into the healthcare market and use their combined market leverage to secure lower-cost healthcare for their 1.2 million employees. At that time, healthcare business experts suggested Haven Healthcare (Haven), as the non-profit joint venture was named, might become a transformative healthcare model other companies could follow.
But that was not to be. In January, the companies announced Haven would close its doors in February. Why did it fail to accomplish its goals? And how will its demise affect the healthcare benefits provided to the thousands of people employed at these companies? The answers to these questions should be of interest to pathologists and medical laboratory managers who want to position their clinical labs as high-quality, added-value contributors to patient care.
One Expert’s Opinion on Demise of Haven Healthcare
In an article he penned for Harvard Business Review, titled, “Why Haven Healthcare Failed,” John S. Toussaint MD, an internist, former healthcare CEO, and founder and Executive Chairman of Catalysis, a non-profit healthcare educational institute, outlined three major reasons for Haven’s closing:
Insufficient Market Power: According to Toussaint, the three companies simply did not have the market power to dominate a large enough share of any local market. In addition, with a combined 1.2 million employees, the companies did not have enough employees to incentivize providers into lowering prices.
Perverse Incentives: In the current healthcare environment, US insurers and providers make huge profits from treating disease. This means there is little incentive to keep people out of hospitals or accept the risks associated with fixed-price capitation.
Poor Timing: The COVID-19 pandemic forced providers to focus on and manage the crisis, which, in turn, caused them to postpone or even cancel elective and non-emergency medical procedures, resulting in financial hits and the unwillingness to take on the uncertainty associated with new, possibly dubious arrangements.
Why Is It Hard to Disrupt Healthcare?
Jeff Becker, Principal Analyst, Healthcare, CB Insights, told Quartz, “Haven is yet another cautionary tale to outsiders [who] hope to disrupt the industry that their ambition is likely unrealistic and that solving key industry problems proves to be far more difficult than most anticipate.”
Other experts point to a vague plan, an overly ambitious strategy, difficulty retaining top talent, a lack of visible progress, and the divergence of interests between the three companies as potential reasons for Haven’s demise, Quartz reported.
Did Haven Healthcare Demonstrate Any Innovation?
It is unclear what the collaboration accomplished or what exactly led to its demise, but it does seem that some positive developments were created through the venture.
According to Forbes, Haven Healthcare stated on its now-defunct website, “In the past three years, Haven explored a wide range of healthcare solutions, as well as piloted new ways to make primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable. Moving forward, Amazon, Berkshire Hathaway, and JPMorgan Chase and Co. will leverage these insights and continue to collaborate informally to design programs tailored to address the specific needs of their own employee populations.”
At least one of the three partners may have anticipated Haven’s closure and taken proactive steps. In January of 2020, Dark Daily reported that Amazon Care launched a pilot program which offers virtual primary care to its Seattle employees, and features both telehealth and in-home care services, including clinical laboratory testing.
At that time, we noted the similarities with Haven Healthcare.
And in “Amazon Building Labs to Do COVID-19 Testing,” Dark Daily’s sister publication The Dark Report covered how, as a result of the COVID-19 pandemic, Amazon built and now operates multiple clinical laboratories for testing its employees.
Amazon has a history of entering an industry and successfully disrupting it. Its willingness to build lab testing facilities to do its own COVID-19 testing may be the first step in a multi-year strategy to enter the clinical laboratory industry and disrupt it by offering better quality lab testing services at a cheaper price.
Thus, it is likely these medical laboratories will continue to deliver clinical testing even after the pandemic has officially ended and will compete with local independent clinical laboratories.
While many of the major gains promised by electronic health records (EHRs) and big data remain elusive, Geisinger Health’s Unified Data Architecture demonstrates how big data might help healthcare providers and clinical laboratories optimize care, improve outcomes, and control costs as the technology evolves
Use of big data in healthcare gets plenty of hoopla these days. Many experts predict great things as clinical laboratory test data is pooled with other patient information and demographic data. But there are many technical problems to be overcome before the full potential of healthcare big data can be translated into ways that improve the health of individuals.
Big data in healthcare is essential to the success of both precision medicine and population health management. However, without the ability to consolidate other data sources and provide intuitive ways for healthcare providers to access, analyze, and utilize the data coming from the various sources, such as clinical laboratory and anatomic pathology test results, much of the data can be underutilized or overlooked.
Consolidating Data to Create Cohesive Snapshots of Patient Health
The HBR report attributes Geisinger’s ability to utilize big healthcare data to its Unified Data Architecture (UDA). According to a Healthcare Informatics article, Geisinger’s UDA was based on Hadoop and other open source software. According to the doctors who wrote the HBR report, “… pulling meaningful data aggregated from many sources back out of EHRs has historically been vexingly complex. The potential insight from these data are limited in practice by the shortcomings of traditional data repositories.”
Geisinger’s UDA addresses two key issues the Healthcare Informatics authors see as obstacles to the expanded, easier use of big healthcare data:
Lack of ways to deal with unstructured patient notes that do not adhere to traditional database organizational structures; and
Data silos created when multiple departments collect data but use separate storage systems.
Big data graphic above from Nuance, developer of intelligent systems for healthcare and other industries, illustrates the challenges involved in acquiring, sifting, managing, and utilizing big data in healthcare. (Graphic copyright: Nuance.)
Geisinger’s system connects nurses on the floor, medical technologists in the clinical laboratory, and surgeons in operating rooms to the same pools of data. However, it also pulls in data from external sources, such as pathology groups, other reference or medical laboratories, and even patient-worn mobile medical devices. The HBR report states, “The integration of data from Health Information Exchanges, clinical departmental systems (such as radiology and cardiology), patient satisfaction surveys, and health and wellness apps provides us with a detailed, longitudinal view of the patient.”
Big Data Helps Healthcare Professionals Spot Future Worries
Geisinger doctors found that AAAs typically are discovered during care for another condition. Often, the conditions for which the patient seeks care are more serious than the small AAA and it isn’t mentioned. While AAAs might be noted in patient records, healthcare providers typically do not look for the data. Thus, left untreated, a AAA can develop into a serious condition that could have been prevented.
NLP enables Geisinger doctors to analyze UDA data for warning signs of AAA and create follow-up and treatment plans that might otherwise remain overlooked. According to the HBR report, this program has led to 12 lifesaving operations to date that might otherwise have been missed.
Real-Time, Comprehensive Updates Offer Big Gains in Combating Sepsis
Big healthcare data shows potential for treating many life-threatening conditions, such as sepsis. Prompt treatment is essential to positive outcomes in sepsis cases. Physicians at Geisinger use the company’s UDA data to both pinpoint when sepsis indicators appeared, as well as to consolidate data from across a patient’s care continuum to optimize treatment.
Instead of sorting through disparate streams of data from various operational areas and reports, data is combined into a consolidated dashboard featuring real-time physiologic metrics, such as:
The HBR report notes, “By tracking, aggregating, and synthesizing all sepsis-patient data, we expect we will be able to both reduce the incidence of hospital-acquired sepsis and improve its management.”
Using Big Data to Track Surgical Supply Chains and Waste
With the unique cost and outcome aspects of each surgical case, and the differences in payouts from payers, creating big data for tracking the efficiency and waste of surgeries is difficult without a big picture view of the factors. Using their UDA, Geisinger can track the exact supplies used in an operation along with the outcome, recovery, cost, and follow-up data related to the procedure.
“This gives surgeons and administrators an important new view of how they perform comparatively from both a cost and outcome perspective,” noted the HBR report’s authors.
Big data is still a developing technology. Nevertheless, programs such as at Geisinger Health offer useful lessons into how data streaming from clinical laboratories, pathology assays, operating rooms, intensive care units, and even personal health-tracking devices might be combined to provide a unified patient record. That would make it possible for caregivers to use analytical tools to tailor each patient’s care and treatment to his or her specific conditions and physiology.
To match the supply of blood products to demand, a clever entrepreneur has created an award-winning business that may help clinical laboratories better manage the cost of blood products in their hospitals and health systems
There’s something new and exciting in the world of blood banking and medical laboratory medicine. It’s a unique approach to matching the availability of blood products to the demand for those same products and it’s catching the attention of medical laboratory directors and blood bankers in many of the nation’s hospitals.
How did an ice storm and a Super Bowl factor into the development of an innovative and disruptive technology that addresses a persistent gap in the US blood products supply chain? In February 2011, central Texas was hit by fierce weather that not only disrupted flights, snarled traffic, and threatened Super Bowl XLV, it also impacted the local and regional hospitals’ ability to access blood for patients in need. Enter a young entrepreneur who saw a critical problem and understood that the raw materials for a solution already existed. (more…)