Healthcare Software as Monday Morning Quarterback

This video provides an in-depth exploration of the role and misplacement of healthcare software within the prior authorization process, using AIM Specialty Health as a primary case study. Dr. Eric Bricker, the speaker, begins by introducing AIM Specialty Health as a major subsidiary of Anthem, responsible for a vast number of prior authorizations across the United States. While acknowledging the impressive technological infrastructure and operational scale of AIM, Bricker critically argues that the sophisticated software employed by such prior authorization entities is fundamentally "misplaced" and operates as a "Monday morning quarterback," questioning physician judgment after the fact rather than supporting decision-making at the point of care.

The presentation details the extensive scope of AIM's operations, highlighting its involvement in prior authorizations for a wide array of medical services. These include advanced imaging (CT scans, MRIs), cardiology procedures (stress tests), sleep studies, radiation oncology (for various cancers like prostate, breast, lung, brain), medical oncology (chemotherapy for leukemia, lymphoma, solid tumors), specialty drugs (e.g., Remicade infusions), genetic testing, and orthopedic procedures (e.g., knee replacements). AIM conducts 10 million reviews annually and facilitates 1,500 doctor-to-doctor peer reviews daily, impacting 50 million lives and serving 40% of Fortune 50 companies. The sheer volume underscores the critical, albeit controversial, role these organizations play in healthcare access and cost control.

Dr. Bricker references a conference video by Phil Merrell, the CIO of AIM Specialty Health, praising AIM's technological prowess. Merrell reportedly detailed AIM's advanced software integrations across various Blue Cross health plans, its utilization of both public and private cloud infrastructure, robust security measures for sensitive health data, and sophisticated application development capabilities. Bricker acknowledges Merrell's work as potentially "one of the best jobs in the entire industry" regarding healthcare technology implementation. However, this commendation serves as a setup for Bricker's central thesis: despite its technical excellence, the software's application is flawed because it's positioned externally to second-guess medical decisions.

The core of Bricker's argument revolves around the concept of "Monday morning quarterbacking," where prior authorization software retroactively judges medical necessity. He points out that the 391,500 annual peer-to-peer conversations (representing 4% of all reviews) are not dialogues of agreement but rather contentious discussions where physicians must justify their treatment plans to an external entity. Bricker contends that all this technological effort and software development should instead be integrated directly into the electronic medical record (EMR) systems within hospitals and doctor's offices. Such an integration would transform the software into a real-time "decision-support tool," empowering physicians with immediate guidance and evidence-based recommendations, thereby optimizing care upfront rather than creating administrative hurdles and delays through post-hoc denials. He concludes by urging healthcare software developers to focus their skills on creating impactful, point-of-care solutions rather than "titanic deck chair straightening software" that addresses symptoms of systemic inefficiency.

Key Takeaways:

• Massive Scale of Prior Authorization: AIM Specialty Health, as a single entity, performs 10 million prior authorization reviews annually and handles 1,500 doctor-to-doctor peer reviews daily, affecting 50 million Americans and serving a significant portion of large corporations. This highlights the immense administrative burden and gatekeeping function of prior authorization in the U.S. healthcare system.
• Broad Scope of Services Covered: Prior authorization extends across a wide range of high-cost and complex medical services, including advanced imaging, cardiology, radiation and medical oncology, specialty drugs, genetic testing, and orthopedics. This indicates that a substantial portion of critical medical care is subject to external review.
• Advanced Software Capabilities: Prior authorization vendors like AIM utilize highly sophisticated software, featuring extensive integrations, public and private cloud infrastructure, robust security, and advanced application development. This demonstrates that significant technological investment is already present in these processes.
• Misplaced Technology and Incentives: The speaker argues that despite its technical sophistication, this software is "misplaced" because it operates externally to "Monday morning quarterback" physician decisions. The current system creates misaligned incentives, focusing on denials and appeals rather than proactive, evidence-based decision support at the point of care.
• Inefficiency of Peer-to-Peer Reviews: A substantial number of reviews (4% or nearly 400,000 annually for AIM) escalate to peer-to-peer conversations, which are inherently adversarial. This represents a significant drain on physician time and resources, indicating a breakdown in initial decision-making or communication.
• Vision for Integrated Decision Support: The core recommendation is that prior authorization software should be integrated directly into hospital and doctor's office Electronic Medical Records (EMRs) as a real-time "decision-support tool." This would enable physicians to make informed decisions upfront, aligning technology with patient care rather than administrative oversight.
• Impact on Healthcare Professionals: The video implies that the current system adds unnecessary stress and administrative burden on practicing physicians, who are forced to justify their clinical judgment to external entities.
• Call to Action for Software Developers: Healthcare software developers are encouraged to redirect their talents towards creating solutions that genuinely improve patient care and optimize clinical workflows at the point of service, rather than building systems that perpetuate inefficiencies or act as external gatekeepers.
• Focus on Upstream Optimization: The underlying message is that healthcare efficiency and quality would be significantly improved by shifting technological interventions upstream, providing tools that prevent inappropriate care or support optimal decisions from the outset, rather than reviewing them after the fact.

Tools/Resources Mentioned:

• AIM Specialty Health's proprietary software
• Public cloud infrastructure
• Private cloud infrastructure
• Electronic Medical Records (EMRs)

Key Concepts:

• Prior Authorization: A process required by some health insurance companies for certain medical services, procedures, or medications to determine if they are medically necessary before they are performed or prescribed.
• Monday Morning Quarterback: A metaphor used to describe someone who criticizes or second-guesses decisions after the event, when the outcome is already known, rather than offering support or guidance during the decision-making process.
• Decision-Support Tool: Software or systems designed to assist healthcare professionals in making clinical decisions by providing relevant information, alerts, and recommendations based on patient data and medical knowledge.
• Peer-to-Peer Review: A process within prior authorization where a physician from the insurance company or prior authorization vendor discusses a case with the treating physician to review the medical necessity of a requested service.