HJBR Sep/Oct 2025

HEALTHCARE JOURNAL OF BATON ROUGE I  SEP / OCT 2025 13 requires one or more additional cuts. Typically, Mohs surgery requires one to two stages of these resections, and rarely a third resection. Makary describes an interview he conducted with the then president of the American Col- lege of Mohs Surgery, the late John Albertini, MD, who had raised concerns about overtreat- ment among some Mohs surgeons. Mohs sur- geons get paid based on the number of staged surgical resections, and the association’s lead- ership had heard multiple reports that some doctors appeared to be doing the operation in too many stages. It could have been that these doctors needed more training — or it is pos- sible that they were motivated by money. Makary had embarked on an initiative titled Improving Wisely, which was like the American Board of Internal Medicine’s Choosing Wisely campaign. The Improving Wisely campaign built on the goals of Choosing Wisely by using physician-led data transparency and specialty- specific metrics to identify and reduce unnec- essary or extreme variations in care, aiming to improve quality, lower costs, and promote more responsible medical practice. Graphic Findings from an Innovative Study Makary and Albertini proposed a Mohs sur- gery research project where they would look at the average number of stages used during a procedure. Most surgeons would fall within a certain range, but some were using many more surgical stages that added time and expense to the procedure and unnecessary surgery for patients. The college leaders bought into the plan. Their intention was not to penalize or even require preauthorization for a doctor to remove a cancer in three stages or more, although they admitted that might become necessary if physician behavior did not change. Data showed that most surgeons averaged between 1.2 and 2 surgical stages per patient over the course of a year, but that some were averaging four or more stages per patient. Ex- perts in the field stated that any high-volume surgeon who averaged more than 2.2 stages per operation was beyond the threshold of what they would consider appropriate. This group, led by Makary, Albertini, and American College of Mohs Surgery leaders, sent a letter to Mohs surgeons across the coun- try that included a one-page report showing each surgeon how they compared to the rest of Mohs surgeons in the country. Graphs depicted where each doctor stood on the bell curve, with doctors averaging three or four surgical stages per case way out on the tail end of the chart. The response was both surprising and fortu- nate. The overwhelming majority of responses were positive and the subsequent results strik- ing. They found that 83% of notified outliers changed their practice patterns for the better, and that over time the reductions in surgical stages appeared to be sustained. Preauthorization: A Broken Tool? One of the most controversial and frequently discussed payer practices among both pa- tients and providers alike is “preauthorization,” which occurs when an insurer reserves the right to determine if a clinical intervention is medi- cally necessary. As a practicing physician, I have been on the receiving end of this practice and can attest to the frustration it can cause. I recall specifically a case where I had ordered a CT of the abdomen on a patient, only to be told that the payer had denied the imaging study. I needed to get on the phone with one of their medical directors and essentially plead my case as to the clinical rationale for the study, which was then promptly approved. That may not sound like a big deal, but when you are trying to see a multitude of patients — and often find yourself running behind be- cause of a myriad of complexities that may arise during the day — even a few minutes of a phone conversation with a health plan medical director is a very unwelcome intrusion, indeed enough to make even the most mild-mannered of us become angry. Preauthorization by health plans, originally intended to control costs, ensure appropriate care, and guard against overutilization, has in- creasingly become a barrier to timely and nec- essary medical services. Physicians and health- care systems report significant administrative burdens and delays in patient care, often with- out clear clinical justification. According to a 2022 report by the Office of Inspector General (OIG) and data from the De- partment of Health and Human Services, 13% of prior authorization denials were for services that met Medicare coverage rules and as many as 75% of denied prior authorization requests in Medicare Advantage plans were overturned on appeal, suggesting that a large proportion of initial denials may not be clinically sound. Similarly, a 2021 survey by the American Med- ical Association found that 94% of physicians reported delays in care due to prior authori- zation, and 30% said these had led to serious adverse events for patients. These two statistics indicate that a significant share of initial denials may not have been clinically justified and that plans often reverse their decisions upon closer review, raising serious concerns about the ef- ficacy and ethics of current preauthorization practices, and suggesting that they often ob- struct rather than facilitate appropriate medical care. More recently, UnitedHealth Group has come under intense scrutiny for allegedly using arti- ficial intelligence algorithms to automate prior authorization denials in its Medicare Advan- tage plans. Investigations, including a 2023 ProPublica report, revealed that UnitedHealth’s subsidiary, naviHealth, deployed an AI tool to predict the appropriate length of post-acute care — often overriding physician recommen- “Preauthorization by health plans, originally intended to control costs, ensure appropriate care, and guard against overutilization, has increasingly become a barrier to timely and necessary medical services.”