People go into medicine for a wide variety of reasons but not a single one of us who has spent years of blood, sweat, and tears looks forward to the cringe-inducing concept of a peer-to-peer. Every clinician I know greets the notification for a peer-to-peer with at least an internal scream if not an audible groan, knowing they will have to jump through a variety of administrative hoops to then spend precious time justifying a decision they already made to someone who may or may not have any real context for the conversation. Friendly, mild-mannered physicians have gotten as close as I have ever seen them to snapping when having to explain over and over again that, “No, botulinum toxin injections are not a new experimental treatment for patients with disfiguring facial synkinesis. No, it is not cosmetic. Yes, the patient has had the exact same treatment in the past with good results. Yes, repeated treatments are necessary. No, there is not a permanent treatment option for this chronic, life-long disorder.”
So imagine my excitement when I was gifted the opportunity to have a peer-to-peer of my own recently. I had seen a patient who had a large silicone implant in his nose after a prior out-of-state surgery. And the implant, as many tend to do, had decided it no longer wanted to remain in his body, eroding through the skin in an effort to work its way out. He had been to the ER three, four, five times in the course of a few weeks due to concerns for infection, each time getting antibiotics but not improving. I saw him in clinic and recommended we remove the implant and then reconstruct his nose a few weeks later, after any infection had resolved. I took photos and wrote a detailed note, outlining his course, prior consults, and outside records. Surgery was clearly indicated, as he had failed multiple courses of antibiotics and his repeated ER visits were certainly not an efficient use of his time or health care dollars. But then I got a message that his surgery was denied and a peer-to-peer review was required. I worked to find a window of time to make the call and prepared my argument. The day came and the insurance company never called. They had the time wrong and I had to reschedule, as I had other patients to see that day. The second time they waited until the last minute to call and then simply said that the patient was out of network so the surgery was denied. Except he wasn’t. Before the call disconnected, I implored them to please, please check the network status again because I was sure he was in network. They reluctantly agreed to it, and a half hour later I got another call — the patient was in network and the surgery was approved. The clinical information was never reviewed or discussed. So much time and effort expended for an administrative error.
The argument from insurers is that such measures are necessary to curb nonindicated treatments or decrease costs when cheaper alternatives are available. A clinician speaking to another clinician is a conversation on equal footing, with both having the medical knowledge necessary to discuss the clinical subtleties of the case, whereas it may be beyond the scope of administrative personnel. But there are a few assumptions in this model that do not bear out in reality. The “peer” representing the insurance company may not really be a peer at all. Sometimes they are not even trained in the same specialty as the ordering clinician, which sets us up for a conversation as fruitful as one I would have with a sports fan about the current NFL season. Having lived in Kansas City for five years I have a go-to party line (Go Chiefs!), but I lack any depth of insight to argue about coaching decisions or referee calls. Even when the insurer’s representative is within the same vein of training, the situation may not be much better.
Within my field of ENT, my colleagues are so sub-specialized that it would be somewhat irresponsible for me to assume I would fully understand the context of decisions made about lateral skull base masses or complex pediatric airway reconstruction. Sure, I could have a conversation and interject if something seems patently unsafe, but that would be the extent of things. Which points out another fallacy in the peer-to-peer set up — motivation. Among colleagues, a conversation about a patient would fall under the assumption that all parties involved want what is best for that patient, are invested in the option that would best utilize the skills of the clinicians involved, and calculate the balance of risks and benefits tailored to that particular situation. But when a payer is involved, that assumption is moot. Insurance companies are stewards of finance, not of care, and to argue differently would be naive. They are businesses first, and businesses survive by taking in more money than they spend. There is a strong motivation, whether explicit or implicit, to defer costly treatments in favor of cheaper ones, to decline to cover surgeries or specialized medications, to deem things not medically necessary, or to push care to in-network facilities even if that may not be the optimal option for the patient. Health care spending in the U.S. is out of control, make no mistake, but recommending a rhinoplasty for a patient with a clearly deformed nose and years of nasal obstruction is not the driving force in this.
The health care insurance system is not going anywhere anytime soon, so the peer-to-peer system is here to stay. So how do we manage the headache? How do we advocate for our patients within the constraints placed upon us? We are pushed to spend less and less time with patients and aren’t compensated for time spent on phone calls or emails or meetings done on their behalf. The peer-to-peer process is another hurdle to jump, one that implies an inherent distrust of our ability as clinicians to make sound clinical decisions and be good stewards of resources. I think we — and our patients — deserve more than that.
How have your experiences been with peer-to-peer review? Join the conversation below.
Heather is the inaugural Facial Plastic and Reconstructive Surgery fellow at Penn State. Her clinical interests include patient communication, medical education, facial reanimation, and complex reconstructive surgery. Heather was a Doximity Op-Med Fellow in the 2021–2022 cycle as well as the 2022–2023 cycle, and continues as a 2023–2024 Doximity Op-Med Fellow.
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