A rheumatologist has penned a screed against prior authorization (PA).
Explore this issueJune 2015
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In a piece posted on the popular online portal, Rheumatology Network, Christopher Adams, MD, chief of rheumatology at the East Alabama Rheumatology Center in Opelika, Ala., and the managed care and governmental affairs liaison for the Alabama Society of Rheumatic Diseases, says he wants to bring attention to the issue of PBMs asking for prior approval before green-lighting patients to receive prescribed medications or outright refusing to provide certain drugs. He expanded on his thoughts earlier this month in an e-mail interview with The Rheumatologist.
Question: You write the burden of (PA) paperwork “hinders us physicians from fighting disease.” Has it really gotten that bad?
Answer: It is far worse than ‘that bad.’ Yesterday, my PA medical assistant spent 95 minutes on hold on the telephone and then was talked down to like a misbehaving schoolchild by [a] PBM representative. I got on the phone and asked why it took all this time to get a patient the medicine that she had taken without administrative hassle for years. The PBM rep tersely instructed me that they have a ‘procedure that must be followed,’ so I asked if their procedure was more important than treating the patient.
Q: Why do you believe it has gotten worse in recent years?
A: Health insurance companies have carved out pharmacy benefits from major medical and other coverage, so there is nothing to buffer cost increases within this bucket of money. The industry appears desperate to take whatever means is necessary to control costs, even if it means denying patients from getting medicines that they have been successfully treated with for years.
Q: What should the rank-and-file rheumatologist be aware of here that maybe they’re not thinking of, in terms of how important this issue is?
A: The basic problem is control. Doctors are still held liable for patient outcomes, but now the decisions about treatment are being wrangled from the exam room to the boardroom. What rheumatologists need to understand is that we have entered a new era with the threshold of disease control and remission for several conditions that we treat, [and] pressures from PBMs are preventing us from implementing [some] dramatically effective therapies.
Dr. Adams believes decisions from PBMs should be transparent, conform to standard-of-care practice guidelines and provide timely responses. To help raise further awareness of how this practice negatively affects patient care and to pressure PBMs, he also suggests encouraging patients to lobby their senators and representatives and insurance companies.(posted 3/27/15)