Here’s what we can do to minimize the daily hassle of prior authorizations
Disruptive and expensive—what could be worse for your and your patients’ morale?
The ‘safety’ catch. Obstacles do not necessarily end when the medication is approved; such approval is merely a “coverage eligibility review.” In addition, PBMs make it clear that every prescription also undergoes a so-called safety review by a pharmacist before it is dispensed. If the PBM’s pharmacist identifies a safety concern, the medication “might not be dispensed,” Express Scripts says, “or your patient could receive less than what you prescribed.”
That is an ominous statement: The PBM is openly and arrogantly taking for itself the right to unilaterally determine what is safe and to override the physician’s judgment as it sees fit. We all know that there are relative risks in taking most medications that we prescribe; the degree of that risk needs to be carefully calculated against the likely benefits for a given patient, whose detailed history is known to the treating physician. History and risk-benefit calculation are not available to the reviewing pharmacist. The existence of “safety concerns” by itself, outside of the full context of care, is insufficient justification for a PBM to stop payment for a medication.
“Approved”—but… Equally ominous is that, after a medication has been approved through the PA process, some PBMs add these words in their notification to the physician:
This medication is approved for coverage until [insert date],
or until coverage for the medication is no longer available
under the benefit plan or the medication becomes subject
to a pharmacy benefit coverage requirement, such as supply
limits or notification, whichever occurs first.
In other words, the approval is provisional, and shouldn’t be counted on to remain in place for the entire period for which dispensing has been approved. Imagine the uncertainty and anxiety of a patient who reads that statement and realizes that the medication that, at last, has relieved her symptoms might be withdrawn from coverage at any time for reasons unrelated to effectiveness.
The patient can appeal the decision of a PBM or insurer that refuses to pay for a medication, but that patient, and his physician, might ask themselves whether the considerable time required to appeal is justified, given that the criteria used for denials are arbitrary and one-sided.
Serious consequences can ensue after a PBM denies coverage for a medication. Some patients cannot afford hundreds of dollars out of pocket for 1 month of 1 medicine. When their supply runs out, they become vulnerable to symptoms of withdrawal or exacerbation of underlying illness.
Armchair care. A PBM, after it has denied approval of payment, might “ask” the physician to choose another medication that the PBM does cover. For a non-physician administrator who has never seen the patient to propose such a switch is micromanagement—to say the least. Such an action is also disrespectful of the physician’s judgment.
Loss of possible placebo effect. If the physician goes along and makes the switch proposed by the PBM, the patient will know that the new medication is the physician’s second (or third) choice. Any potential positive placebo effect is thus lost. Does that matter? It might—a lot.
Most physicians would be glad to have a positive placebo effect assist or augment the physiologic effects of a medication, especially at the start of treatment when the patient might feel helpless or hopeless. Such negative feelings are likely to be magnified if the patient knows that he has been coerced into taking a second-line therapy. A positive placebo effect, on the other hand, might well have lowered levels of his stress hormones for a few weeks—and that effect could have made a positive difference.
Casualties for the physician are time, money, and morale. PAs consume large chunks of time. Some of the PA forms require that 20 or more questions be answered; a few of those questions can take significant time to answer, having to look through a thick chart to research prior medications.
PAs also cost money: directly to pay the salary of staff that share the PA work, indirectly by crowding out the doctor’s potential billing time and replacing it with uncompensated PA work.
Worse, in my opinion, is the cost to morale. Physicians express their annoyance, aggravation, frustration, and anger at meetings and in postings at the end of journal articles on the subject. Some speak of becoming numb from the daily hassle of dealing with PAs.2 The disrespect for the physician’s decisions inherent in the PA process, the implicit humiliation of appealing to someone who doesn’t know the patient to approve payment for a medication that’s been legally prescribed, and the cost in time and money all provoke emotions that are damaging to morale.
