Since December 2015, The Hawaii Medical Service Association (HMSA), one of Hawaii’s largest insurance companies, has required physicians to get prior authorization from National Imaging Associates in Phoenix, Ariz., for all diagnostic imaging exams.

The news began causing headaches throughout Hawaii almost immediately. Requesting prior authorization can take up a significant amount of time, and being told to get approval from someone all the way in Arizona leaves physicians feeling they aren’t trusted or respected.

On Feb. 29, Elizabeth A. Ignacio, MD, president of the Hawaii Radiological Society (HRS), and Christopher D. Flanders, DO, executive director for the Hawaii Medical Association (HMA), wrote an open letter to all Hawaii physicians, saying “the frustration of dealing with preauthorization via third party reviewers who are thousands of miles away is readily apparent” and suggesting that everyone use clinical decision support that uses the American College of Radiology’s Appropriateness Criteria.

“HRS and HMA are completely committed to working with Hawaii’s insurance carriers to build and support sustainable health care systems for the people of Hawaii,” Ignacio and Flanders wrote. “Our goal is ho‘ohiki—keeping our solemn promise as physicians to fully deliver the highest quality of healthcare that we can provide.”

Ignacio spoke with RadiologyBusiness.com about the situation:

RadiologyBusiness.com: Can you touch on the impact this change from HMSA has had on radiology throughout Hawaii?

Elizabeth A. Ignacio, MD: The impact of these problems is primarily felt in the horrible delays that our patients undergo as they wait for prior approval for their high tech imaging studies. But certainly the changes have a profound impact on the radiology centers in Hawaii. The revenues are down for outpatient imaging centers statewide from 30-50 percent. Hawaii Radiology already is at the lowest quartile of reimbursement for imaging care, and now with the new prior authorization changes, many of these outpatient centers will not be able continue to operate. Compounded by the ongoing physician shortage of Hawaii (we are presently down 900 physicians for our state compared to the rest of the nation), the severe repercussions are real.

How has this situation impacted patients and patient care?

The patients’ encounters with prior authorization have been frustrating, uncomfortable, and dangerous. Patients not only endure suffering the anxiety of an unknown critical illness, they experience ongoing pain, and risk advancement of their condition from urgent to emergent.

As a result, the emergency rooms are being accessed to bridge this gap in care, encouraging overutilization of an even more expensive solution.

HMSA has said this situation is temporary. Do you know what exactly this means? Do things go back to how they were at a certain point?

It is unclear what their original intent for the time course was when they made these changes. But HMSA’s promise to bring back the “fast passes” to a few select providers will definitely not solve the overall problems of transparency and national guidelines that Hawaii physicians feel is at the heart of these issues.

The open letter you co-wrote with Christopher D. Flanders was addressed to physicians in Hawaii, suggesting they all being using specific CDS software. Why not write directly to HMSA officials? Why advocate for CDS use at this specific time?

It is a complex situation, and your question is a good one. The HMA and HRS decided to approach the problem first by educating our physician community that a reasonable solution exists and why this was a superior tool to complement the Hawaii provider physician’s efforts, delivering nationally approved evidence-based guidelines from the ACR.

With the unified support of the Hawaii physicians and their documented experiences, HMA and HRS were in a better position to discuss the limitations, delays and problems of prior authorization to the insurance carriers, and introduce the CDS solution on firm ground.

In March, a bill passed the Hawaii House that prohibits insurers from requiring prior authorization of medical services that causes a delay in patient care. The bill, a reaction to HMSA’s decision, is now being considered by various Senate committees. Did the HRS play any role in getting this legislation moving so quickly?

We have asked for our Hawaii physicians and patients to speak out and provide testimony regarding the serious problems here with insurance prior authorization. Through their honest and compelling accounts, the legislators can begin to understand the barriers that physicians and patients encounter when trying to find a diagnosis and start treatment.