Prior Authorization Is Likely Only Going to Get Worse
https://www.medpagetoday.com/opinion/patientcenteredmedicalhome/116599
Check out what happened when I tried to authorize a prescription refill … for myself
The world of prior authorization, and the hoops we need to jump through, has gotten just more and more ridiculous, bordering on the absurd, and I’m worried that things are about to get much worse.
Many of us have likely already encountered the loopholes and the barriers to prescribing GLP-1 medication for our patients for weight loss. A colleague recently showed me a form they’d been asked to fill out, where it had a series of questions about the patient’s body mass index (BMI), and then an additional series of questions seeking to justify whether, for this particular BMI, the patient really “deserved” to get this medicine.
The questions were separated by BMI ranges of two points, e.g. a BMI of 27 to 29, 29 to 31, 31 to 33, and on up through the 40s and beyond. For each BMI category, the insurer requested information about how long they’d had that BMI, what the patient had done to try and lose weight, what complications they’d suffered; the insurer also requested documentation in the form of office notes for the past year.
Interestingly, this happened after the insurer had already received, in the first round of trying to get this medicine for the patient, the office notes that my colleague had written documenting all of this: the patient’s current BMI, their weight loss history, as well as their efforts to lose weight through the years.
My colleague had tried just checking off the appropriate box for the particular BMI range that this patient was in, but the form had been returned to them for being “incomplete.” The insurance company required them to check “No” to every BMI range that the patient was not in, and then “Not Applicable” for each of the next series of questions associated with that irrelevant BMI range. This was now the third level of form completion that my colleague had been forced to go through. They persevered, but many would’ve certainly given up.
On a more personal note, I recently had to send in one of my own prescriptions to the pharmacy, because the doctor I see for this particular medication is in solo practice, and they were away for a well-deserved summer vacation. I went ahead and e-prescribed the medicine — not a high-risk medicine, controlled substance, or anything potentially concerning or even very expensive, just one of my routine medications — to the mail-order pharmacy.
Later, I got an email saying that they had attempted to reach the prescribing physician without success. After I reached out to them, I learned that additional prior authorization forms were needed. Much to my surprise, I, as the patient, then received an email from the insurance company stating that I, as the doctor, had declined to fill out a prior authorization, and that I, as the doctor, had subsequently canceled the request for the prescription.
Trying not to get too upset, I called the insurance company, entered my date of birth and the last four digits of my Social Security number, and finally was connected to a representative. They told me that my doctor had initially not responded to their efforts to reach them, either by phone or fax or email, and finally when he was contacted, he reported that the prescription was no longer needed. They were quite surprised when I advised them that the patient, Fred Pelzman, had the same name as the physician who had prescribed that medicine, Fred Pelzman. After much backpedaling, they finally connected me to a supervisor, who said they would look into the matter, and then — magically, suddenly — the prior authorization was approved.
In tough financial times, with more and more restrictions cropping up, we’re likely going to see more limitations on what we are able to prescribe for our patients, both in the world of pharmaceuticals, and in terms of labs, imaging, and other testing. Insurance companies are going raise the bar on what’s required for us to practice medicine as we see fit, and this just seems wrong. And when we rise up to jump over that bar, they will likely raise it again.
Sure, there’s probably still plenty of fraud, abuse, and overuse, and a lot of overprescribing, overtesting, and overtreating, but it seems pretty obvious that the restrictions that these companies put into place have not done anything to improve care, have contributed to patient dissatisfaction and provider burnout, and have not made a dent in the 18% of our gross domestic product that we spend on healthcare. Perhaps, instead of more thoughtless rules, we could design a better, smarter, and more connected health system, with a strong base in primary care, something that is equitable and available to everybody.
With looming cuts to healthcare coming from Washington, this may become harder and harder, as the insurance companies and hospital systems get pushback from their shareholders and the bottom line. And it must be true that these are tough times to operate in. But somehow, despite our best intentions, the system has continued to evolve and grow into a massive tangled web that’s nearly impossible for patients and physicians to navigate through.
I recognize that my retirement plan is vested in many of these companies, and in our current capitalist system everybody should be allowed to profit on their efforts. But as bad as the system is already, with doctors unable to prescribe the medicines they think their patients need, or get them the imaging they think they should have, or get them into a specialist in a timely manner, things are only going to get worse.
Unless we stand up and fight, and insist that healthcare is a right.
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