Yet, some Part D plans require authorization for inexpensive drugs, such as prednisone. This confusion and inconsistency led Dr. Eisenberg to a straightforward view of the pre-approval process. “This is another layer of hassle with no purpose. Patients should get what they need with less hassle factor,” he says.
Alfred Denio, MD, a rheumatologist at the Center for Arthritis and Rheumatic Diseases in Norfolk, Va., agrees. “There is usually a good reason a doctor does not use a drug on a formulary list [and instead uses] one that is already working but not on the list,” he claims. “The reason is comorbidity.”
Like most rheumatologists, Dr. Denio has patients who, because of their age, are being treated for several diseases that are often chronic. For example, a patient with RA, diabetes, asthma, heart disease, and high blood pressure needs a carefully balanced drug regimen for effective treatment and safety. The choice of medication for any one problem, therefore, may not be an easy decision—nor can it be a decision dictated by an insurance drug formulary.
Logistical Questions Remain
In addition, the prior authorization process itself causes logistics problems. A patient can appeal a drug denied by his or her plan and can also request a reconsideration (level 2) appeal on a denied Part D claim. This is the point at which the patient can appoint the physician to represent him or her in the claim, which requires a form signed by both the physician and the patient that is good for one year.
One of the early complaints is that patients in rural areas, such as those in Dr. Morris’ Appalachian areas and Dr. Smith’s remote northern New Mexico regions, have to travel long distances to sign the authorization form. In addition, the staff in the physician’s office have to complete the paperwork and follow up throughout the process—either by mail, fax, or telephone.
This erosion of staff time has become a cost factor for many practices. Herb Baraf, MD, who works in one of the largest practices in the country in the suburbs of Washington, D.C., puts it succinctly, “The ability to get through the day is degraded terribly.”
In fact, Dr. Baraf considers this problem so important to some practices that they are forced to close down for a day a week to balance costs. “This is not our motto in our practice,” ensures Dr. Baraf, “but it can be a problem for many practitioners.”
