The call can come while Adetokunbo Oyelese, MD, PhD, is seeing a patient. At other times, it interrupts an operation.
Dr. Oyelese has stepped out of examination rooms and scrubbed out of surgical procedures to join peer-to-peer reviews with insurers. The purpose is usually to defend care for someone who is not in the room: a patient awaiting an MRI, a procedure or a spine operation scheduled for the following week.
The reviewing physician may agree with his clinical reasoning. The authorization may still run into an insurer’s scrutiny.
For Dr. Oyelese, director of the spinal surgery division and the Norman Prince Spine Institute at Providence, R.I-based Brown University Health, prior authorization is no longer simply paperwork. It is a system that repeatedly pulls physicians away from one patient to argue for another.
“This is a very significant inconvenience not just to the surgeon and the practice,” Dr. Oyelese told Becker’s. “It’s a great disservice to the patient who’s just looking for a diagnosis and a way to get better.”
His argument is not that prior authorization should disappear, as insurers have legitimate reasons to question unnecessary treatment. He added that spine surgeons also have to acknowledge how the specialty’s financial incentives and enthusiasm for new technology helped produce the scrutiny they now face.
He said the problem is although the current system can be necessary, it also can be adversarial and poorly equipped to recognize clinical nuance.
A denial system rife with friction
Patients and physicians enter the authorization process with similar goals, Dr. Oyelese said. The patient wants to know what is wrong and what can be done. The surgeon wants the diagnostic testing necessary to understand the condition and, when appropriate, a treatment likely to improve it.
The insurer must manage spending and determine whether the requested service meets its coverage requirements. That difference does not make review improper. Prior authorization can protect patients from unnecessary care, particularly in a fee-for-service system in which clinicians and institutions are generally paid more when they deliver more treatment.
Dr. Oyelese said the system breaks down when the review becomes less about evaluating the patient and more about finding a reason to stop the request.
Insurers are increasingly using automated systems to examine documentation for omissions or inconsistencies, he said. Some gaps may be clinically meaningful; others may have little bearing on whether the proposed treatment is appropriate.
Either can produce a roadblock. An automated system can review documentation almost instantly. A physician must interrupt clinical work, schedule a peer-to-peer discussion and reconstruct the reasoning behind a decision already reached through an examination, imaging review and conversation with the patient.
The burden itself can become part of the cost-control strategy, Dr. Oyelese said. If the process becomes sufficiently difficult, the physician or patient may stop pursuing the request.
Peer-to-peer review is designed to add clinical judgment, and Dr. Oyelese appreciates being matched more frequently with physicians who understand spine care. But specialty matching has limited value when the reviewer cannot depart from a fixed coverage algorithm.
Spine created some of its own scrutiny
Dr. Oyelese does not place all the responsibility on insurers.
“We in spine surgery have, over the last several decades, done ourselves a disservice,” he said.
Most spine surgeons are trying to make appropriate decisions for their patients, he said. But fee-for-service medicine can create conflict: The physician recommending an operation may also be paid to perform it.
Dr. Oyelese recently evaluated a patient who had been offered cervical surgery elsewhere. He said her MRI findings were normal for her age and did not explain her symptoms. The proposed surgeon would have been paid regardless of whether the procedure improved her condition. Cases like that can harm an individual patient, increase spending and invite broader restrictions across the specialty.
“If we don’t police it ourselves, the government will come in and police it,” Dr. Oyelese said.
He said spine surgeons and professional societies should take a stronger role in defining evidence-based indications, identifying inappropriate practice and reinforcing defensible standards.
Preventing oversight from becoming automatic denial
The prior authorization debate is often framed as a choice between physicians and insurers. Dr. Oyelese sees a more difficult balance: A physician should not have to fight repeatedly for well-supported care, but an insurer should be able to challenge a procedure that lacks a credible indication.
The solution, he said, is a more substantive system of dialogue, preferably developed with leadership from the spine community.
Such a system could distinguish physicians with consistent, evidence-based practice from those whose patterns warrant greater scrutiny. It could also give reviewers enough discretion to recognize when a patient does not fit neatly inside a standardized pathway.
Rigid criteria are vulnerable to two opposite errors. They can approve care because the correct boxes were checked even when the operation is unlikely to help. They also can deny appropriate care because the patient does not resemble the average case used to write the rule.
The challenge is building oversight strong enough to prevent abuse without making clinical complexity itself grounds for denial.
New technology’s obstacles
Insurers are naturally skeptical of technologies that are new, expensive or lack long-term outcome data, Dr. Oyelese said. Some of that resistance reflects cost containment. Some reflects the history of spine innovation.
Spine surgery is often driven by technological development: a new implant, imaging platform, navigation system or operative approach. That can place products into clinical use before the field knows whether they will improve patients’ lives over the long term.
“Spine surgeons, we love sexy tools,” Dr. Oyelese said. “We love new shiny objects.”
The initial question is often whether the surgeon can implant the device or complete the operation successfully. Another important question is what happens five or 10 years later. Does the patient function better than someone who received the traditional treatment? Does the technology prevent revisions or complications? Does it produce enough value to justify its cost?
Dr. Oyelese uses advanced navigation, intraoperative imaging and augmented reality. His immediate justification is not that every patient will have a superior long-term outcome because a particular platform was used. It is that the technology allows the surgical team to verify hardware placement before the operation ends.
If that reduces the risk of bringing a patient back to the operating room for a misplaced screw, it may prevent harm and avoid the cost of another procedure.
That is a legitimate value proposition, he said, and is different from claiming that the technology transforms long-term outcomes.
For example, a long reconstruction extending from the thoracic spine to the pelvis can appear extreme when reduced to procedure codes, implant costs and a hospital bill.
The value becomes clearer when the patient is standing in front of the surgeon, Dr. Oyelese said. He described patients who have spent years walking bent forward, unable to travel even a short distance without substantial pain. A major deformity correction may restore an upright posture and return a level of independence the patient had lost.
The operation is extensive. So is the disability it is intended to treat.
“You straighten them up, and they have a new life,” he said. “That is invaluable to that patient.”
Complex spinal oncology creates an even sharper version of the same tension. These procedures may serve relatively small patient populations and require highly specialized teams and significant hospital resources. In some cases, however, they offer a chance at survival or function when no meaningful alternative exists.
That does not place complex surgery beyond scrutiny, Dr. Oyelese said, adding that extensive procedures still require strong indications, realistic goals and an honest assessment of risk. But complexity should not be mistaken for excess simply because the operation falls outside a reviewer’s experience.
Incentives can shape clinical decisions
Dr. Oyelese said reducing inappropriate care also requires examining incentives within spine programs. The question is not only whether insurers encourage denials. It is whether physician compensation encourages operations.
At Brown, Dr. Oyelese said, the spine team’s compensation model is designed to reduce the potential financial penalty for directing a patient to a colleague with more relevant expertise.
He explained the approach with a familiar metaphor: A patient should not become a nail simply because the surgeon is holding a hammer.
A comprehensive spine program brings together specialists in areas such as minimally invasive surgery, deformity, oncology, trauma and endoscopy, making it easier to match patients with the clinician best suited to their condition rather than the first surgeon they see.
That only works, however, if compensation and governance encourage collaboration instead of competition. In a well-aligned model, physicians have less incentive to keep cases within their own practice, reducing inappropriate procedures before prior authorization is ever needed.
A gatekeeper capable of judgment
Dr. Oyelese’s position contains uncomfortable concessions for both sides.
New technology deserves scrutiny. Rigid rules can also prevent patients from receiving appropriate innovation. Complex surgery is expensive. It can also restore or preserve a life.
He said a credible reform effort must hold those realities together.
The answer is not simply fewer denials, it is better decisions.
That will require transparent criteria, timely review, meaningful specialty expertise and a stronger willingness within spine surgery to confront inappropriate practice. It will also require payment models that reward physicians for directing patients toward the right care rather than the most care, he said.
The real question, according to Dr. Oyelese, is not whether spine care should have a gatekeeper. It is whether the gate is capable of recognizing the patient standing in front of it.
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