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“Dear Doctor Maisel,” the letter from the insurance company read, “Remicade, the medication that you prescribed for Miss X, requires a prior authorization, and is being denied at this time.” Miss X is one of my many IBD adolescent patients. She has an eight year history of Crohn’s Disease for which it took years to achieve a remission, now on Remicade for the last six years, living a healthful life. I get that visceral response, put my head in my hands and groan. I remember that it is January, the beginning of a new year and the insurance “approval” cycle, requiring new prior authorizations for all my patients with chronic medical needs. The nursing staff then presents me with another fifty letters calling for prior authorizations that have also arrived the same day. The work begins (it actually is a nightmare that never ends)! Several staff start pulling EMR charts, electronically sending to some insurance companies, but having to print and fax to others, to justify the various medications, labs, imaging studies, referrals and procedure orders. There is usually a response within 48 hours. For Miss X, the response comes the next day. The Remicade is denied, with the rational that she has not been off the medication in over one year, and that in order to receive approval for its use, she has to be challenged with lower tier medications, including prednisone, for at least two months, and fail treatment. Another groan. My staff sets up a “peer-to-peer review” in three days, for which I have to make myself available despite being in the OR. The phone call comes. The “peer” is a physician with no background in my field, with little knowledge of Crohn’s Disease and even less knowledge about its treatment. He does not understand the danger of putting my patient in relapse, the difficulty of pulling her out of relapse, not to mention the increased expense to the insurance company to do so. He does not understand that Remicade treatment cannot be interrupted without the associated risk of developing an antibody to the medication and never being able to use it again. I explain the rationale for the medication and the importance of not interrupting the treatment. I try to keep a lid on my rising frustration when he asks me to send him “peer-reviewed” journal articles to support my stance – I have a library of articles, just for this purpose, on most of the medical interventions I order. I call my staff, back in the office, requesting them to locate the articles and fax to the “peer” – I hear from him the next morning that the medication has been authorized. Not only is there a six day delay in administering the medication, placing the patient at risk of relapse, but also a cost in time and salary to my office, for a medication that was going to be approved anyway – I have never had a denial sustained for ongoing therapy for this medication. Yet, for the 150 IBD patients that our office infuses every 4-8 weeks, and the hour of time required for each approval (on-hold time; transfer from agent one, to agent two, and then to agent three; time to locate EMR chart, and then location within the chart for the relevant information, and subsequent re-entering the chart to send additional information not initially requested; print and fax time; physician peer-to-peer time) – you do the math, my head spins, and the cost of medicine climbs. I can’t imagine how much of our insurance premiums go to insurance company mid-level “denial” staff, for whom the majority of denials dispensed are going to be overturned. Wait, the process is not over! Even after the insurance companies approve the medical request, payment gets denied, and the same records have to be resubmitted again before payment can be received. More staff time and expense to the system.
Prior authorizations were initially developed as a cost savings measure to encourage prescribing of lower cost alternative medical therapies and procedures, to lower the cost of medical care. However, the system has become overly regulated, over-reaching, over-used and an increasing burden to physicians. The majority of the cost-savings benefit is being seen by the insurance companies. The current prior authorization process places a substantial, uncompensated burden to providers who are already struggling to cover costs. The physicians are frustrated and the patients are caught in the middle. “There is patient frustration and an erosion of trust when the patient arrives at the pharmacy and discovers their prescribed medication is not on the insurance formulary, or that the labs, imaging studies or procedures prescribed by their physician, as the best course of action, have been denied by the insurance company, rejected as being frivolous and inappropriate to the diagnosis. The patient does not see the hours of work involved in obtaining prior authorizations and appealing denials. The patient sees the letter from their insurance company and likely interprets it as “your doctor does not know what he is doing, the insurance company is there to guide your physician in making the right choices.” Our patients are not aware of the soaring cost of time and staff necessary to negotiate the prior authorizations and appeals to treat even the most basic afflictions, including medications for constipation and reflux, much less more complicated diagnoses. The patients are only aware of the delays in their treatment, the expenses they incurred, because their physician “did not get it right” according to the patient’s insurance company. Frequently, physicians do not have enough time or staff to obtain the authorizations, or when they do, are at legal risk when they “bend” the diagnosis to get the authorization due to insurance company semantics. And in the end, when physicians do pursue the denial, it is almost always overturned, but at what cost? The physician-patient relationship erodes a little more.”**
The American Medical Association is trying to address the situation by having convened a 17-member coalition of physicians, medical groups, hospitals, pharmacists and patients to urge reform of prior authorization requirements related to medical tests, procedures, devices and drugs. The coalition states that the current process of insurer pre-approval is delaying or interrupting medical services, diverting significant resources from patient care, and complicating medical decisions. The coalition’s formation was precipitated by two AMA studies. The first study included a poll of 1000 physicians, 40% primary care/60% specialists, with the following results:
Each week the average practice completes 37 prior authorization requirements per physician. These requests take the doctor and his or her staff an average of 16 hours to complete.
Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
More than a third of respondents reported having staff who work exclusively on prior authorization.
Nearly 60% of surveyed physicians reported that their practices wait at least one business day, on average for prior authorization decisions. More than 25% of respondents said they have to wait three business days or more.
The other study was a survey of 38 physicians, finding that they would like payers to streamline and add transparency to prior authorizations or eliminate them all together. Multiple participants said that they spend 15 minutes to two hours on the phone trying to obtain a single prior authorization. Some plans, they said, require doctors to try things that they know won’t work as part of “step therapy.”
The coalition is calling for an industry-wide reassessment of prior authorization. A set of 21 principles has been grouped into five categories: clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and “alternatives and exclusions.” The alternatives and exclusions could include relative pass-throughs for physicians that have low rates of denials (“gold card”), higher restrictions on physicians that are “outliers,” and exemptions for physicians in organizations that take financial risk for care delivery.
Some of the principles for prior authorization reform are related to 1) clinical validity of prior authorization denials, 2) qualifications of the reviewers, 3) plan policies that result in unwarranted interruption of therapy (i.e., unexpected formulary changes, or care coverage that negatively impacts the patient’s care and access to care). The coalition stresses that prior authorization approvals should be valid for the course of the treatment. They further stress that they should be made within 48 hours of obtaining necessary information, and within 24 hours for emergencies. In addition, the coalition is calling for transparency about utilization review requirements and the supporting documentation that is required.
I was impressed by the full report of the coalition and encourage you to review, download and distribute the 21 principles to your colleagues and staff (Prior Authorization and Utilization Management Reform Principles). Well worth reading! I am further encouraged by the evolution of ePA products becoming available to automate the prior authorization process – 85% of EMRs are linked to an automated ePA – however, their use is limited by the widespread lack of awareness of the software. The American Medical Association has composed model legislation that physicians and patients can draw on to promote meaningful changes to the prior authorization process (Model Bill: Ensuring Transparency in Prior Authorization Act), another must read! I challenge the Indianapolis Medical Society to convene a forum in the next few months to propose and promote legislative changes to current prior authorization policies that are logical, individualized, health promoting and not just cost-saving. The Medical Societies of Colorado, New York, Minnesota, North Carolina, Ohio and Washington State are on the AMA coalition. Let us be the next organization to join the legislative effort for reform!
** October 2016 President’s page