I read the April 10 article by John Frank, (“Prior authorization bill seeks to address ‘cumbersome’ process) and wanted to reply. Prior authorization and radiology “review” are programs designed by third-party payers to reduce their costs. As physicians, we have allowed this process to accelerate out of control and become progressively burdensome.
Prior authorization is essentially asking the physician to do his work again, to try to save money for the insurance company. This abuse is even more apparent in radiology review programs.
A few egregious examples should serve to demonstrate how abusive the process is.
I recently had a patient on only generic prescriptions for diabetes, lipids, and blood pressure. This patient had survived a stroke two years ago. When her prescriptions were submitted for renewal to [pharmacy benefit manager (PBM)] OptumRX, each prescription was denied. After multiple communications, the patient’s drugs were slightly changed, but she was without medication for several days. Fortunately there were no negative effects.
Another case involved a patient with a history of ulcer disease who had local back pain, which responded to lidocaine patches. When the prescription was submitted for renewal, the PBM denied it because it was not for post-herpetic neuralgia. This drug is also generic, improved patients’ quality of life dramatically, and certainly is safer than narcotics, muscle relaxants, and NSAIDs in a patient with ulcers.
A final example of moronic approach to prior authorization is manifest in a patient case of a gentleman on Oxycontin (15 mg), who was sent through the process, and a new prescription for 10 mg required a new prior auth.
I would propose that a moratorium on prior authorization is the answer. Doctors should refuse to participate at all. Consequences of not paying for needed medications should fall to the PBM and insurance companies. PBMs are the worst kind of “middle man.” Their assistance was not sought by doctors nor patients, but by another “middle man”— payers.
Let us start to redirect the system to patient care and concerns first. Accurate formulary information during real-time prescribing would remove the need for prior authorization.
If Congress feels compelled to “help” limit new and patented drug costs, I would propose a 200 percent “tariff” on any prescription drug advertising. This cost has no benefit to any part of the healthcare system. It also might help balance the federal budget.
Michael Berard, MD
College Park, Md.
Drug plan info shouldn’t be a game of hide and seek
While electronic prior authorization can help, they should be combined with easy-to-find drug plans. When I look up a patient’s eligibility with the insurer, the plan should be there. And, when I receive an electronic notification of the prior auth needed, I should have a link to that patient’s drug plan.
Instead, we have to search for it—never sure if we’ve found the right one—and Medicare plans are doubly tricky as the drug plan seems obscure and hard to even name, much less find.
In response to “Value-based care will add fire to physician burnout”:
So called “value-based care” is a one sided equation and will never work. It does address the biggest obstacle to obtaining quality outcomes, namely the ability of the patient to afford their medications or patient compliance with doctor’s orders.
If you can’t afford the medications, do not take them as instructed, and do not change your diet, exercise regimen or quit smoking, then outcomes reflect only one side of the reimbursement equation. This is simply another way for government and third-party payers to line their coffers on the backs of what was formerly known as the medical “profession,” now known as the “healthcare industry.”
Trey Kirby, DO