Patients

Prior Authorizations: Will They Become Damocles Sword?

By NIRAN AL-AGBA

Niran Al-Agba, MD, FAAP

In July 2009, the family of Massachusetts teenager Yarushka Rivera went to their local Walgreens to pick up Topomax, an anti-seizure drug that had been keeping her epilepsy in check for years. Rivera had insurance coverage through MassHealth, the state’s Medicaid insurance program for low-income children, and never ran into obstacles obtaining this life-saving medication. But in July of 2009, she turned 19, and when, shortly after her birthday, her family went to pick up the medicine, the pharmacist told them they’d either have to shell out $399.99 to purchase Topomax out-of-pocket or obtain a so-called “prior authorization” in order to have the prescription filled.

Prior authorizations, or PAs as they are often referred to, are bureaucratic hoops that insurance companies require doctors to jump through before pharmacists can fulfill prescriptions for certain drugs. Basically, they boil down to yet another risky cost-cutting measure created by insurance companies, in keeping with their tried-and-true penny-pinching logic: The more hurdles the insurance companies places between patients and their care, the more people who will give up along the way, and the better the insurers’ bottom line.

PAs have been a fixture of our health care system for a while, but the number of drugs that require one seems to be escalating exponentially. Insurance companies claim that PAs are fast and easy. They say pharmacists can electronically forward physicians the necessary paperwork with the click of a mouse, and that doctors shouldn’t need more than 10 minutes to complete the approval process.

But in my experience, that’s rarely the case. In order to get my patients the drugs they need, I regularly spend more than half an hour on the phone with ill-trained customer service reps who don’t know the first thing about pharmaceuticals and whose job description consists of being as obstructionist as possible.

And I’m not alone. A video by an independent physician with a sense of humor documented his Kafka-esque bid to obtain a PA for a patient. The video lasts 21 agonizing minutes. And studies have shown that PAs gobble up at least 20 hours per week in the average physician’s office. Even in an age when many aspects of practicing medicine in the United State have become nightmarish, PAs hold a place of particular sinister distinction.

Now, back to the Rivera case in Massachusetts. After Walgreens declined to fill Yarushka’s Topomax prescription, her family returned to the pharmacy four more times –each time without success. (It’s unclear whether or not Walgreens ever actually sent an authorization request to the physician’s office.)

Without the drug she’d relied on for years, Yarushka had three seizures. The last one proved fatal.

Her grief-stricken family subsequently filed a wrongful death suit –not, as might be expected, against the insurance company that required the PA in the first place, but rather against Walgreens, Yarushka’s physician and his practice.

To my mind, this case gets it all wrong, and in so doing, potentially dangles Damocles’ sword over the heads of each and every physician and pharmacist practicing in the United States today. The fact is that both Yarushka’s doctor and the Walgreens pharmacist did their jobs: Her physician issued a prescription for the life-saving anti-seizure drug, and the pharmacist tried to dispense the medication. It was Yarushka’s insurance company –not the physician or the pharmacist- that was the monkey wrench, arbitrarily denying coverage for her medication without any reasonable justification.

Medical malpractice is defined as negligence by act or omission in cases where the prescribed treatment fell below the accepted standard of practice and caused injury or death. In the Rivera case, MassHealth alone created the barrier between Ms. Yarushka and her life-sustaining medication.  The insurance company was, effectively, practicing medicine without a license. And it alone should be held accountable for the tragically predictable outcome after overriding the sound judgment of her physician and pharmacist.

But because of a legal doctrine called sovereign immunity, which shields states from civil or criminal prosecution, it’s highly unlikely that MassHealth, a state-run insurer, will ever face legal consequences Yarushka’s –or any other, for that matter.  How many more patients have to die before we force insurers to prioritize patients over profit?

The Rivera case is still winding its way through the court system in Massachusetts, but a verdict against Walgreens will open a Pandora’s box for medical professionals across the country, effectively holding them legally liable for the decisions and practices of an all-powerful third party that’s under no obligation to follow their medical recommendations.  If MassHealth is not held accountable for causing the wrongful death of Yarushka Rivera, then more insurers will be emboldened to practice medicine without a license, which will surely lead to the deaths of countless other patients nationwide.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State who blogs at peds-mommydoc.blogspot.com.

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Will_Roll_TidePharmaviewpjnelsonHans Duvefelt MDSteve2 Recent comment authors
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Will_Roll_Tide
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Will_Roll_Tide

I realize I am a little late to the game, but I am here. 🙂 From a patient’s perspective, I cannot hold my pharmacy or my physician (or other providers) responsible for something invented by and installed by insurance companies. That would be the same as blaming my cell phone provider because my trash was not collected. Yes, I used my cell phone to call and initiate trash collection service. But what does that have to do with the price of eggs in China? (I know, it should be rice… thank my mother for that.) I am an insulin controlled… Read more »

Pharmaview
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Pharmaview

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pjnelson
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pjnelson

Another view of the PAs is that they exist as a result of the provider agreements principally originating between the insurance companies and the Complex Healthcare Providers, aka tertiary medical centers. The irony, of course, is that they have never exhibited a vested interest in the affairs occurring at the front-lines of healthcare. Any carrier tries to maximize its profit margin in spite of the annual increases in reimbursement requested by the Complex Healthcare institutions. It is most precisely defined as a very large institutionally co-dependent relationship. No wonder they are unable to exhibit autonomy in behalf of their constituent’s… Read more »

Hans Duvefelt MD
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Hans Duvefelt MD

Ironically, topiramate is now on Hannaford pharmacies’ $4 list.
We all have tragic and ridiculous stories about PAs:
https://acountrydoctorwrites.wordpress.com/2014/08/11/calling-mrs-kafka/

Barry Carol
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Barry Carol

Doctors persist in claiming that insurers just care about profits while insurers say that doctors just want to be left alone to practice medicine as they see fit, they want their bills paid quickly and without question and they want their prescriptions filled without any hassle for their patients or themselves. Both patients and employers complain loudly and often about the high and rising cost of health insurance. Of course, health insurance is expensive because healthcare is expensive. A reasonable balance needs to be struck here since money is the constraining resource and we’re already spending close to 18% of… Read more »

Niran Al-Agba
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Niran Al-Agba

“reasonable balance sheet”: Stephen Hemsley annual income 2014 $66 million, Niran Al-Agba, MD 2014 $89,000. You are right Barry. Doctors are totally unreasonable. Years of education: Stephen Hemsley 4 year bachelor degree. Dr. Al-Agba 4 year bachelor, 4 year for MD, and 3 years of pediatric residency (annual income average $22,000 during those 3 years.) CEO’s direct “culture” of the organization: Dr. Al-Agba does CPR on a 10 day old baby in her clinic while waiting for an ambulance to arrive. Child survives and was admitted to a children’s hospital ICU. $70 bill is rejected by United Health Group because… Read more »

Barry Carol
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Barry Carol

The CEO compensation and education line makes for a nice liberal sound bite but even if the 25 most highly paid executives of every insurance company all worked for free and the savings were used to reduce insurance premiums, the price reduction would be a small fraction of 1%. United’s revenue will be north of $200 billion in 2018. Moreover, United’s premiums are competitive with those of the non-profit Blues where executives are paid a lot less because there are no stock options and RSU’s to award as non-profit entities. I didn’t say that primary care doctors are a big… Read more »

Niran Al-Agba
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Niran Al-Agba

First of all, many physicians including myself have spoken with members of Congress about healthcare. They don’t understand it any better than you or other laypeople do. As for what I’m implying, you have it completely backwards. I am making the point that physicians should not be held accountable for negligent acts on behalf of the health insurance company. The insurance company should be legally responsible for this death. Not the pharmacy and not the physician. PAs for New or extremely expensive medications certainly makes sense when there are suitable cheaper alternatives.

Res Morgan M.D.
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Res Morgan M.D.

Physicians have no contracts with PBMs, have never been given instruction on what they expected to do or how to do, have no authority to reverse any bad decisions made by others, and are not paid for their work – yet, apparently, they can now be sued for anything that goes wrong in the pre-auth process.

Chilling.

Niran Al-Agba
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Niran Al-Agba

Dr. Morgan…. YES! This exactly. You nailed the point of this post perfectly. Here we are with no authority, no control over basic scientific decision making, and basically doing the work for free of prior authorizations — and now, we can be sued for something we did not create. I think all offices should have a “No PA policy” to protect us and then if we think a certain med is necessary we can CHOOSE to do the PA without liability if it is rejected.

Barry Carol
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Barry Carol

It makes no sense to me to hold physicians or pharmacists accountable for a rejected or unreasonably delayed pre-authorization decision by an insurance company or PBM. More broadly, I think we are one of the most litigious societies in the world if not THE most litigious. Physician practice patterns must take that cultural reality into account and is one of the big reasons, in my opinion, for why healthcare costs are significantly higher here than in other developed countries. There is way too much defensive medicine delivered out of necessity. To be clear, I don’t blame doctors for that either.… Read more »

Niran Al-Agba
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Niran Al-Agba

Fair enough, Barry. For what it is worth, that is the larger point of this post: holding the pharmacy or physician responsible for a medical decision they did not make is ridiculous and will scare a lot of physicians away.

Res Morgan M.D.
Guest
Res Morgan M.D.

“Maybe it’s time for doctors, hospitals, drug companies, insurers, employers and PBM’s to stop talking past each other and try to find some solutions”

If it is taken as a given that everyone is fairly paid for their work, great.

If it’s assumed that physicians have to work for free in order for the pre-auth process to function, don’t bother.

You seem to be unwilling to agree that physicians should be paid for their work doing pre-auth. I don’t understand that.

Barry Carol
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Barry Carol

My about to retire cardiologist told me that about 50% of his time in recent years is spent on things other than direct patient care. This includes everything from reviewing reports from hospitals, imaging centers, labs and specialists to fighting with drug companies and insurers including dealing with pre-authorization requests. You may not be aware but Princeton’s late health economist, Uwe Reinhardt, told us that the value of a Medicare relative value unit breaks down as follows: 52% covers the physician’s skill and technical effort, 44% covers practice overhead, and 4% is attributable to malpractice insurance. In other words, there… Read more »

Res Morgan M.D.
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Res Morgan M.D.

Straight Medicare is great in terms of the low hassle level; Medicare Advantage plans generally are the worst of all, with lots of pre-auths required for generic drugs. I tend to avoid them.

Anyway, the RVU system was designed before 2 hour pre-auths were common.

And, as Dr. Al-Agba indicates, pre-auths frequently come out of the blue unconnected to an office visit or procedure, so you’re talking about 44% of zero RVUs which comes to . . .

But, patients are entitled and expect all this for free.

Barry Carol
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Barry Carol

Could you make a reasonable living if you had to accept Medicare rates from all comers? If Medicare pays too quickly and too easily with little or no oversight, it increases the risk of fraud which has long been a significant problem. As a taxpayer, that’s a concern to me. I assume you know there is no such thing as a straight Medicare Part D drug plan. All Part D plans are private plans. Some are part of a Medicare Advantage plan called an MAPD plan while others are stand-alone Part D plans. After 6 1/2 half years on straight… Read more »

Steve2
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Steve2

Have to agree that the use of pre-authorizations seems pretty indiscriminate and aimed at saving money for the insurance company, regardless of the necessity of the medication or procedure. Also, this is something to remember when we talk about administrative costs in medicine. Admin cost estimates often do not include the costs on the provider side. There are substantial costs incurred with PAs and even just following different billing rules when dealing with the different insurance companies. Miss a rule change sent out by the insurance company and it can cost you big bucks. (True experience, not conjecture.)

Steve

Res Morgan M.D.
Guest
Res Morgan M.D.

This sad story seems to be quite complicated. Apparently, the patient was out of Topomax for at least two months, during which time she was hospitalized at least once for a seizure and discharged with a Topomax rx that wasn’t filled. She suffered her fatal seizure while at a mental health facility (not clear if inpatient or outpatient); they are being sued by the family for having unlicensed staff, but not, it seems, for not giving her Topomax.

Very sad.

Niran Al-Agba
Guest
Niran Al-Agba

Actually Dr. Morgan, the Supreme Court in Mass just ruled that indeed the lawsuit against Walgreens CAN go forward for not following up on the PA request. It appears the mental health facility part is a completely separate legal action from what I can tell.

Barry Carol
Guest
Barry Carol

This is a sad case to be sure but are you suggesting that prior authorization is NEVER appropriate and shouldn’t exist? What about quantity limits on certain drugs; are they wrong too? Insurance premiums would go through the roof if payers had to pay for every service, test, procedure or drug without question. Don’t you think doctors are involved in establishing the formulary and individual drug restrictions in the first place? When I developed atrial fibrillation in 2015, I was prescribed Eliquis but it required prior authorization. my doctor had to jump through some hoops to get it approved for… Read more »

Res Morgan M.D.
Guest
Res Morgan M.D.

Anecdote: back when Merck owned one of the first big PBMs, they were causing incredible chaos for doctors, patients, and pharmacists in our area. Working up the phone tree, I got hold of a regional manager of some sort and said that along with other doctors in the area, I would pay my staff to meet with a rep from their company and learn how to use their system. Or if that wasn’t possible, how about sending us some printed guidelines with accurate phone numbers. Her response to both proposals was a blunt “No – we don’t consider that a… Read more »

Barry Carol
Guest
Barry Carol

It was a clear conflict of interest for Medco to be owned by a drug company (Merck) so it was eventually acquired by Express Scripts. Express Scripts is about to be acquired by Cigna. While I’m sure there is room for improvement in the process of getting pre-authorizations approved so it doesn’t consume as much physician time, I can guarantee you that self-funded employers and insurance companies would not hire PBM’s to manage their drug benefit if it didn’t save them a significant amount of money vs. what it would cost to manage it themselves. That’s why we have formularies,… Read more »

Res Morgan M.D.
Guest
Res Morgan M.D.

‘there is room for improvement in the process of getting pre-authorizations approved so it doesn’t consume as much physician time” Sure there is, but it won’t happen – it will only get worrse. Why would PBMs invest in more staff and equipment – it’s doesn’t cost them a penny to keep a doc on hold for 30 minutes. “self-funded employers and insurance companies would not hire PBM’s to manage their drug benefit if it didn’t save them a significant amount of money” And a significant part of those savings are achieved through the free labor of doctors and their staffs,… Read more »

Niran Al-Agba
Guest
Niran Al-Agba

You summed it up perfectly. “It doesn’t cost them a penny to keep a doc on hold for 30 minutes.”

Niran Al-Agba
Guest
Niran Al-Agba

We should be compensated for our time. Can you imagine a lawyer doing a PA for free? It would never happen. There was a physician who successfully sued the insurance to be paid for his time. Some physicians are charging patients for the time spent doing prior authorizations. Primary care physicians have families to support too, just like everyone else.

LeoHolmMD
Guest
LeoHolmMD

If you got Eliquis anyway, what exactly was the point of the PA? The only thing it accomplished was punishing your physician and undermining their practice. You also understand that some of the NOACs are demonstrating superiority and safety above Coumadin in certain studies.

There are some categories of medications that contain apples and apples, certain blood pressure medications for instance. Neuroleptics are not one of those categories. People who are on a stable seizure medication under control need to be left alone. There is the potential for harm when switching medications and it should not be taken lightly.

Barry Carol
Guest
Barry Carol

My doctor explained to me that there are three levels of afib — occasional, paroxysmal, and persistent / sustained. Mine was persistent and he thought one of the newer drugs was best for me. A relative of mine has occasional afib and has been doing fine on Coumadin for the last 12 years. A 30 day supply of Eliquis costs 106 times as much as a 30 day supply of Coumadin based on Walmart’s price of $4.00 for Coumadin. Even if the newer drugs are somewhat better, how many people would we have to treat to avoid one stoke event… Read more »

Niran Al-Agba
Guest
Niran Al-Agba

Dr. Holm is correct. Withdrawing people who are stable on seizure medicine is medical malpractice and insurance companies (who are choosing to do this to save $$$) should be held responsible.

Niran Al-Agba
Guest
Niran Al-Agba

Barry, I am so glad you asked what I see as THE most important question about this entire sad situation. No, there is no alternative to Topomax . Seizure drugs in children are more of a precise science than say Afib (sorry). One drug may work for one person and another may not prevent seizures even if the two children have similar types of seizure disorders. This was a $400 drug and absolutely tragic results. To address your other question… I did not say PA’s should not exist. However, to withhold a medication that has been on the market since… Read more »