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Commentary: Insurers, Pharmacy Benefit Managers Increasingly Control Practice of Medicine

Not What the Doctor Ordered:
Increasingly, the practice of medicine is being controlled by pharmacy benefits managers and insurers

Commentary published Dec. 5, 2013 in the St. Louis Post-Dispatch (Link to article)

By Kenneth G. Poole, Jr., MD
President, Mound City Medical Forum

As the fight for Missouri Medicaid expansion forges on, decision-makers in our state should focus their attention on another issue that faces patients and doctors regularly. This bureaucratic nightmare has the potential for damaging consequences, both financially and otherwise.

Increasingly, the practice of medicine is being controlled by pharmacy benefits managers and insurers. Treatment for patients is often stalled at the pharmacy counter because arbitrary systems — designed to rein in costs — are keeping patients from the medications that will help them most.

Essentially, the insurance company gets to decide what medication it will cover, regardless of what the doctor is recommending to best meet patient needs.

It’s called “prior authorization” and it means that patients must wait until the insurance company says it’s OK to use a certain drug — often contrary to what the prescribing physician recommends. It is enormously frustrating as a doctor to prescribe a specific medication for a specific patient’s ailment, only to be put through a round-about process that can include hours of paperwork, days and even weeks of waiting — while the patient goes untreated — and then potentially be denied for the treatment!

According to a 2010 survey on prior authorizations by the American Medical Association, physicians and staff spend a combined 20 hours per week on average just dealing with prior authorizations. This clearly contributes to administrative waste in physician offices, where claims management can consume over 10 percent of practice revenue. A 2009 Health Affairs report estimates that prior authorizations cost U.S. physicians $23.2 billion to $31 billion a year. In addition, the delays caused by the pre-authorization process have been known to land patients in the emergency room, as their condition goes unchecked and unmedicated — a much more expensive, and obviously more dangerous, course of treatment.

In my practice as an internist, I see a lot of younger patients. One of my patients, a young man, came in with full-blown diabetes and he needed a full array of effective medicines to get it under control as soon as possible to avoid continued damage to some key organs of the body. More than a week went by before we could square away with insurance and the pharmacy the medicine I knew would help him the most. I am mindful of costs, and always seek to be prudent in my testing and treatment, but this was a difference of $15 or $25 at most. Meanwhile, it is hard to know what the wait will mean for his long-term management of disease. And, it is unlikely to be his last encounter with such obstacles.

Many states, including Missouri, have taken steps to improve the prior authorization process and streamline other access issues patients face. But there needs to be more done, such as process standardization and automation. Furthermore, patients should be aware of these obstacles when choosing the right health plan.

This year, Gov. Jay Nixon made his first appointments to a committee that will report on efforts to standardize electronic prior authorization. This is a good first step and long overdue.

Patients should also be on the lookout for so-called “step therapy” requirements insurers may force on them, when a patient is required to fail on a specific medication, or medications, before being authorized — by the insurer — to take what their physician had prescribed in the first place.

All of us involved in the health care field should be focused on improving quality and care for patients. Endless paperwork and needless delays are definitely “not what the doctor ordered.” I hope to see great progress from the governor’s committee, and I urge patients who are enrolling in health plans to take a close look at the fine print to make sure that their plan will give them access both to care and the medicines they will need.

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