Insistence on prior authorization (PA) when prescribing certain pharmaceuticals has grown considerably over the past 5 years. Most requests for PA are issued by pharmacy benefit management (PBM) companies that have been contracted by an insurer. A PA can be triggered when a physician orders:
• a brand-name medication
• a medication not on the formulary of the PBM
• a quantity above an arbitrary ceiling
• a medication that has multiple indications (that is, the PBM won’t pay for indication X but will pay for indication Y).
What are the problems caused by PAs? I outline a number of them, and their potential consequences, in this “Commentary.” What can we do, in our practices, to lessen the disruption they cause and the time and money they cost us (Box)?
’Prior authorization’—a misleading, disingenuous term
The physician’s prescription is legal authorization for the patient to receive the medicine. It would be more accurate if PBMs labeled what they do “prior approval for reimbursement.”
PBMs exist to manipulate and coordinate the demand for medication generated, on one hand, by patients and their physician and, on the other, by the cost of supplying portion of that demand. The cost of a medication to the PBM is controlled by:
• negotiating rebates with drug manufacturers
• advantageous contracting with pharmacies
• denying payment, when feasible, using the PA system.
The goal of the PA is to boost the profits of the PBM—not to pay for the best fit between the needs of the patient and the medications available, as determined by the treating physician.
The games begin!
The PA process usually begins when the patient goes to the pharmacy, prescription in hand, and gives it to the pharmacist, who enters it into the computer. At that point, if the PBM has put a block on paying for the medication, 3 things happen in sequence:
1. The computer alerts the pharmacist about the block (or that a higher copay is required).
2. The pharmacist tells the patient something about the block—although not necessarily the whole story.
3. The pharmacist tells the physician’s office (by fax, e-mail, or telephone) that the PBM wants authorization and that the physician must call a toll-free telephone number to obtain that authorization.
The physician’s office then makes the initial call to the PBM. That call can take 10 to 20 minutes, answering preliminary questions. The call generates a questionnaire from the PBM that is faxed to the office, filled with questions that one could characterize as loaded. The questionnaire is intended to provide grounds for disapproval or approval—not to obtain in-depth understanding of the individual patient’s needs.
Playing pieces on a chessboard
Note that the physician and pharmacist, thrust unwillingly into the middle of this gambit, spend considerable uncompensated time on the PA process. (Primary care physicians and their nursing and clerical staff, spent, on average, 19.8 hours a week obtaining PAs in 2006.1)
PBMs have shifted responsibility for communication to physicians and pharmacists by requiring that the physician always contact the PBM. A PBM will not contact a physician directly, either to begin the PA or ask questions during the process.
If the request for authorization is denied, what’s the outcome? The physician’s office and the pharmacist have spent uncompensated time taking action that resulted in the PBM and the insurer improving their bottom line without benefit to anyone else.
Communication breakdown. The cumbersome, multistep PA process opens the door to miscommunication. This happens often, I’ve found: The physician wastes time because the pharmacist passed along an incomplete message, or a patient gives vague or confusing information in trying to transmit what the pharmacist said. Sometimes, when physicians get through to a live person at the PBM, they are told that the pharmacist misinformed the office: No, the medication didn’t require PA after all.
Why can’t PBMs streamline the process, sparing busy physicians’ offices the time spent on initial telephone calls, by installing software that would allow the pharmacist who first encounters a payment block to, with a few keystrokes, instantly send the relevant questionnaire to the physician’s fax machine or computer?
Obstacles to satisfaction
From the perspective of the patient, the word that probably best characterizes his emotional response to the PA process is “helpless.” He wasn’t expecting a denial; it’s likely that he hadn’t been fully or clearly informed at the time he selected the insurer that he might someday face such an obstacle. Even though he had a legal prescription, written by a physician, any attempt to go back to the insurer or the PBM to complain is rarely successful. If he tried, he would likely get no satisfaction: The clerk at the other end of the telephone would swiftly inform him that there were a number of complicated rules, policies, or “step programs” that must be adhered to before the PBM pays for a prescription.
Even if the medication is covered, the patient might be told that there are “quantity limits” that prevent reimbursement for the prescription as written—limits that were not made explicit when he signed up for the insurance plan. All these obstacles can generate confusion, anxiety, frustration, and anger—understandably so.