How Current Peer-To-Peer Sessions Profoundly Impact Patient Care and Physician Wellbeing

I spent the first 12 years of my career in the Navy, where surgeons saw patients, determined what was medically needed, and then added the patient to the next available surgical date. My transition to civilian healthcare had a steep learning curve. I vividly remember my first peer-to-peer. I was home for the holidays waiting for the scheduled call that never came. After more time on the phone rescheduling, the call finally came 30 minutes late as my entire family waited for me to start dinner. I felt that I needed to do this for my patient. Eventually, my practice hired a wonderful PA to cover peer-to-peers. Recently, however, while she was on maternity leave, I took back the responsibility. Many years later, I still find the process burdensome, and my frustration has increased. It’s not only an inconvenience, but increases the cost of delivering care, decreases access, and profoundly impacts physician wellbeing.

Think about the cost of the hours spent by clinical and administrative staff gathering and submitting documents to insurance, waiting to hear back, appealing the initial denial, and then scheduling the peer-to-peer. Some insurers just deny without even the opportunity for a peer-to-peer.

Think about the patient who has taken time off work, has family come into town, is preparing to have surgery, and is waiting by the phone days before surgery to find out if they can receive care.   

Think about operating room personnel and use. The room is staffed and ready to provide care, only to sit empty when surgery is cancelled a few days prior. 

Think about the patient who could have been scheduled for surgery and instead had to wait longer for care.  

Think about the surgeon, who has spent at least a decade in training and frequently cares for very specific disorders hundreds of times a year, speaking to a provider who has never seen the patient and whose job is to question their clinical judgement. The process is demoralizing and disempowering. Even when speaking to polite and knowledgeable providers during peer-to-peers, I can’t help but to feel like I’m on trial for fraud and having to defend my integrity so that my patients can have the needed procedure. What about our oath to do no harm? It attacks a core physician tenet—to care for the patient. Even when approval is obtained, the feeling of victory is short lived as it’s no guarantee that the insurance company will pay for the surgery after it’s performed.  

Fraud exists in healthcare and should be stopped, but those providing consistent, high-quality care should be innocent until proven guilty. Physicians should advocate for “Gold card” laws such as the one pioneered in Texas, where surgeons with high insurance approval rates or documented outcome improvement receive expedited approval. This can reduce costs, increase patient access, and allow physicians to regain a sense of autonomy. Decreasing the burden on practicing surgeons can allow them to focus on why they became surgeons: to care for patients.    

—Robin