Help for Prior-Authorization Overload

Practicing medicine is no longer simply prescribing the medications that we think are best for our patients. In our current times, there are many factors that go into the decision of what medication a patient will take.

Most insurance companies have their own formularies and rules about what medications they will cover. And these change frequently. It is impossible for doctors and pharmacies to stay on top of these because they are all very different. Even the databases we rely on to look these up are often out-dated. As a result, it often happens that a pharmacy calls about a prescription, asking the provider to either do a prior-authorization or to change it to another medication.

Prior-authorizations (PAs) are a big burden in most practices, but especially in primary care ones because we prescribe all classes of medications and treat most diseases to some degree.

How are PAs a burden?

  • PAs result in many phone calls and faxed messages from pharmacies, tying up the phone lines and time at both the pharmacy and the doctors’ offices. Sometimes, all the work is done for the PA and coverage is still denied. This whole process can sometimes take days to complete. It is a red tape burden on the doctor and his/her staff and the patient can be left untreated until an insurance company decision is reached.
  • Many doctors no longer do PAs because of the burden and just prescribe alternate medications. While this may be reasonable in many cases, often the patients are not getting the medication their provider thinks is best for them and their condition. Some pharmaceutical companies offer assistance with PAs. However, as a family doctor, I deal with hundreds of medications and just cannot keep track of all of them.
  • Patients get angry when they cannot get the medications they want so they often cast blame on the doctor or pharmacist. Time is spent listening to their wrath—over something we have little control over.
  • Appeals for denied medications can take weeks to resolve. Patients need to be on medications for a reason and making them wait weeks for a decision is unsound and dangerous in many cases.

No one would argue that we all need to rein in rising healthcare dollars. As physicians, we are aware of this fact and try to prescribe generics where appropriate. However, forcing us to do so where inappropriate is harming patients and driving up costs in its own fashion. The requirement to do PAs is steadily increasing and taking away our own decision-making regarding how we treat patients. Pharmaceutical companies try to help, but we need more if we are to reduce this burden. Having contacts to call for assistance is great but who has time for the phone? We need online resources and help in battling third parties decisions. Formularies should be based on evidence, not politics, and doctors should all have a voice in what medications are included.

  • Linda Girgis, MD, FAAFP

    Linda Girgis, MD, FAAFP, is Owner of Girgis Family Medicine LLC. Currently affiliated with St. Peter’s University Hospital and Raritan Bay Hospital, Linda also writes for Sermo, Physician’s Weekly, the Library of Medicine, and others.

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