“If a provider wishes to prescribe a medication that is not preferred … the provider must go through an escalating appeals process that may involve talking to a clerk, a pharmacist, a nurse, a ‘peer review’ (another MD, but typically not a rheumatologist), a same specialty review, and in the case of Medicare, an Administrative Law Judge. Each of these steps may take 10–30 minutes, during which time the provider is taken away from caring for other patients. … Policies requiring that a provider try therapies in a specific order are referred to as step therapy or fail first protocols. [T]hese are primarily based on cost rather than efficacy.” 4
ACR President David Daikh, MD, PhD, carried the same message to the Department of Health and Human Services, in response to its request for “identification of actions that states or the federal government could take to support the development and operations of a health care system that provides high-quality care at affordable prices for the American people.”5
In his statement, Dr. Daikh made the following recommendations to the Centers for Medicare and Medicaid Services:6
- Ensure that peer-to-peer reviews are conducted with a physician in the same subspecialty as the prescribing physician;
- Restrict prior authorization to physicians whose prescribing practices differ significantly from their peers;
- Publicly disclose all drugs that are subject to restrictions, and provide this information through electronic medical records.
Too Much Transparency?
Dr. Daikh’s and Dr. Harvey’s recommendations speak to the importance of transparency to make healthcare coverage work. With the system we have now, it is almost as if we are all learning to play chess without the benefit of knowing the rules. We learn the rules on the fly, by watching as our pieces are taken from the board and resolving not to make the same mistake twice. We learn to overdocument and undertreat, using regimens that we know are doomed to failure, because we must demonstrate that failure to gain access to the drugs that might actually help our patients.
This implies, of course, that there are rules. This commonly held assumption may require reexamination. This reexamination was initiated by a young man named Gillen Washington, a 24-year-old college student who happens to have common variable immunodeficiency and requires routine treatment with intravenous immunoglobulin.7 His treatments were approved, until suddenly, they were not. Mr. Washington’s appeals had fallen on deaf ears.
It turns out that Mr. Washington’s appeals had fallen far short of the ears in question, which belonged to Jay Ken Iinuma, MD, who was the medical director for Aetna for Southern California at the time. Dr. Iinuma was charged with reviewing and, ultimately, denying Mr. Washington’s appeal for intravenous immunoglobulin. Indeed, Dr. Iinuma’s signature appears at the bottom of the denial for preauthorization that Mr. Washington had received.
