The fight against prior authorizations

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Editor’s Note: Physicians Practice’s blog features contributions from members of the medical community. The opinions expressed are that of the writers and do not necessarily reflect the opinions of Physicians Practice or its publisher.

When medical school applicants ask me for pre-interview advice, I tell them, “When they ask you why you want to go into medicine, don’t say ‘I want to help people.’ That’s what everyone says.” And everyone says it because we want to care for others.

Sure, we love science and the human anatomy (and aren’t phased by bodily functions or fluids). Practicing medicine has a pretty good guarantee of a comfortable, albeit not luxurious, lifestyle. But unless you really want to help people, there are much less stressful and more lucrative career paths.

We spend several years and thousands of dollars learning how to practice medicine because we want to do good. We want to make the diagnosis and manage the disease process. We want to educate and improve people’s well-being. Doing all that can be physically and emotionally exhausting, but it can also be exhilarating and deeply satisfying.

And yet, in today’s healthcare system, we cannot perform the most basic task of caring for our patients. When I started practice a little less than 20 years ago, I didn’t have to get prior authorizations (PAs) for drugs. At least, not very often.

Now, there are all these nonmedical people dictating what tests or drugs are and are not available. Now, I’m forced to deliver the bad news to my patients after mumbling to myself “I hate insurance companies” for the nth time that day that. Now, I must submit three or four PAs a day - and that doesn’t count the prescriptions I change because I am certain the PA will get denied.

I’ve reached a point where I feel like there’s no point in even trying. Once the insurance company says, “Brand X is not preferred. Formulary alternatives are Y and Z,” I know the PA questions will include “Has the patient tried and failed Y and Z?” and “Does the patient have a contraindication to Y and Z?” If you answer no, Brand X is denied. It doesn’t matter that the patient has been on Brand X for a decade and Y and Z didn’t exist then. If he hasn’t previously tried them with no benefit, he has to switch.

I wouldn’t mind so much if the insurance company’s reason was based on clinical studies showing Brands Y and Z are superior, but it usually isn’t. Sometimes, data that suggests certain drugs are superior are the formulary exclusions. In some drug classes, the preferred drugs are changed annually, back and forth and back and forth, among the members of the class.

Physicians battle with insurance companies daily to get the medications their patients need. We also have to wrangle with insurance companies for tests to be performed. For example, I have a patient with an adrenal mass. The American Association of Clinical Endocrinologists (AACE) guidelines say to reimage after three to six months. My patient was a little lax in scheduling, so it was eight months later when she called to say she needed a precertification. It was rejected.

Her insurance company’s policy is to reimage after 12 months. I even did a peer-to-peer review. My “peer,” a non-endocrinologist, told me the insurance company would not cover the test any earlier because it follows different guidelines from the AACE.

My patient had to anxiously wait for the next four months before her insurance company would cover her test. Her anxiety translated into multiple phone calls to my office staff and me. I understand, of course, but I am also frustrated that I can’t care for her. My hands are tied by insurance companies.

And now, pharmacies have started interfering as well.

There are many things that contribute to what is being called physician burnout: the increasing cost of doing business, decreases in reimbursement, increasing regulations, changes in patient expectations of physicians and physician practices, and online reviews.

In my opinion, the biggest obstacle we face every day, and the one most likely to result in burnout, is payers and pharmacies interfering with our medical expertise. Their desire to save a buck is antithetical to delivering what we believe is the best care for our patients. The healthcare system needs to put patients back at the forefront and let physicians practice medicine. Maybe then we can start improving patients’ lives.

Melissa Young, MD, FACE, FACP, is sole owner and solo practitioner at Mid Atlantic Diabetes and Endocrinology Associates, LLC. As such, she is both actively involved in patient care and practice management while also raising two kids and a dog in suburban New Jersey.