August 12, 2014

Prior Authorizations: Insurance Companies: "Yes!" Doctors: "Ugh!"

An op-ed piece from a doctor in the August 3, 2014 edition of the New York Times opened my eyes about a well-intentioned practice that apparently burdens our country’s already out-of-control healthcare costs: “prior authorizations.”

Here’s how it works: in an effort to keep the lid on costs – a worthy goal – insurance companies regularly send letters to doctors in an effort to make them rethink a costly treatment they’ve prescribed and to choose instead a cheaper alternative.

On first blush, it’s hard not to support the practice. If there’s any healthcare theme we see repeated ad nauseum in the media, it’s unnecessary costs.

But in fact, according to the op-ed letter’s author, Dr. Danielle Ofri, prior authorization “is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles.”

Dr. Ofri cites a recent study that offers this conclusion: prior authorizations drain about 20 hours per week from every medical practice in America:

  • 6 hours of clerical time
  • 13 hours of nurses’ time, and
  • 1 hour of doctors’ time

The Doctor Almost Loses It
Ofri describes one case – she calls her patient Mr. V – that apparently precipitated the NYT piece. Mr V had high blood pressure that had been very difficult to control pharmaceutically without exacerbating the side effects from his diabetes, kidney disease, and valvular heart disease.

After years of experimenting, Dr Ofri and her her patient finally came upon a combination of four different blood pressure meds that worked for him. Both of them surely thought the solution a major cause for celebration.

Then, Mr V changed insurance carriers, and a rep from the new company sent Ofri a letter challenging her prescribing him 90 pills of a particular medication every month.

Immediately, she called the company to resolve the matter. Twenty minutes later – after negotiating a series of frustrating phone trees, Ofri heard the insurance rep tell her the limit on that particular med was 45 pills per month. Ninety pills every month was not acceptable.

More Phone Trees, Time,and Questions
Her own blood pressure rising, Dr, Ofri had to work her way through three more phone trees in order to speak with three more customer care reps, because the request for 90 monthly pills for that particular medication was taxing the computer system. The maximum number the program would accept was 45 pills each month.

The fourth representative asked for a complete list of all the blood pressure meds -- and combination of meds – that Mr V had taken while under her care, along with the history of his bp readings, including lab results.

Assembling the the record was a monumental task for Dr. Ofri. Finally, the insurance company employee asked, “But has your patient ever TRIED taking just 45 of these particular pills every month?”

Ofri recalled her own reaction:
Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”
She finally got the prior authorization and ends her letter with this comment:
In the end, we were able to keep Mr. V's blood pressure under control. My blood pressure, however, was a different story, 

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