Monday, April 7, 2014

Prior Authorizations - An Incredible Waste of Time

Anyone who has read this blog in the past is aware of my opinion of middlemen in health care and how they waste everyone's time and run up costs.  Pharmacy Benefit Managers (PBM) remain there right up at the top.  The PBM is the company that your doctor calls to get authorization so that an insurance plan will pay for all or part of a specific prescription drug.  It has never been more clear to me that their sole function is to be an obstacle to the physician, the pharmacist and the patient.  The goal of that obstruction is to increase the likelihood that anyone of those parties will give up at some point and either not fill the prescriptions or accept a different product that is less expensive, less effective, or one that has more side effects.  I am sure that the pharmaceutical companies have gamed the system to make it harder for PBMs to deny claims on a scientific basis.  They can do this by maximizing the number of FDA approved indications up front.  In many cases that results in a product with multiple diverse indications so that the newer medication can be prescribed based on secondary indications.  The physician, pharmacist and patient are left to deal with all of the unnecessary bureaucracy in between.

I posted my interaction with a PBM sometime ago and named them in that post.  I learned about the power of corporate America as a result of that post.  The VP of the company involved called me the next morning and wanted information about the patient involved.  One thing led to another but the bottom line was that I pulled that post as a result of that sequence of events.  Since my position has not significantly changed since then, the companies involved here will remain nameless.  Keep in mind that identical transactions occur tens of thousands of times per day in the United States as PBMs and pharmaceutical companies battle for the healthcare dollar at your expense.

I am still working on the theory about how the VP of a PBM hears about a post on an obscure Internet blog and calls me the next day.  The only three theories I have at this point are:

1.  NSA grade Internet surveillance system by the managed care cartel.

2.  A reader wants to see me silenced because they disagree with my viewpoint or just dislike psychiatrists.  They forwarded the link to the company named in my original post.

3.  My reputation as a tireless crusader against managed care and all of its associated systems.  Well not so much a crusader, but there have been some memorable moments.  Like a conference where I was speaking out against managed care - rather vehemently only to have the VP of one of these organizations remark:  "Dr. Dawson - don't you work for a managed care organization?"

If I did - they never censored me.

Back to the case at hand.  I was called originally by a pharmacist and had no information about the situation.  I had to call her back and ask for a fax.  I got the fax and it contained the prescription and a number for the PBM.  I called and got their endless and indecipherable telephone queue.  After typing in the correct identification number 3 times and saying it once (I thought I would forgo the voice recognition system that is set up to not work) I was put on hold and connected with a human.  He asked me to "verify" in a line by line manner all of the data already on the faxed form.  After wasting those minutes he talked about pulling up the prior authorization points as though he was going to call in another person for that detailed process.  After  a long pause (I am sure that many of my colleagues lose it at this point) he asked me the indication for the drug.  This drug has only one indication and I told him.  He said:  "It's approved."

That sequence of events, taking a total of about 20 minutes would be enough to piss off any intelligent person, but then he said:  "The office can call the pharmacy and tell them the prescription is authorized"  I was momentarily confused and said "What office?"  He said: "Your office."

That's right.  Here we have a sequence of events that starts at the pharmacy with the PBM telling the pharmacist that prior authorization is needed.  The pharmacist has to talk to me twice on the phone and send me a fax.  And I have to complete this waste of time by calling and acting like an agent of the PBM.  Just to be sure that I wasn't being totally lied to I asked the pharmacist if it was true that the physician's office had to call and complete this sequence from hell.     Her response was "It's about 80:20 from the doctors' offices."

Call me a dinosaur.  Call me a hot head.  But this exercise in helping corporate America make more money, while taking valuable time away from me, my employer, my patients, and my family is an abomination and a manipulation.  It can exist only in a country where corporate welfare is the rule of the day and conflict of interest is at all levels of government.  From the perspective of corporate America prior authorization is a good way to get physicians and pharmacists to work for them for free.  From the physician's perspective - it is a complete waste of time.

George Dawson, MD, DFAPA

Supplementary 1:  Although the sequence of events listed above may sound incredible it is not.  I have dealt with PBM telephone queues where there was no way out.  You could not enter the numbers by keypad or say them through voice recognition.  There was no way to speak to a human.  I had to call the pharmacist back and explain that the prior authorization through the PBM was basically a sham and if the patient wanted the medication they would need to pay for it out of pocket.

It would be a lot more honest if the PBM would just tell people: "We make money by denying your prescriptions and in an ideal world we would prefer to not have to pay for anything."

But I guess that would be bad for public relations.


  1. "But this exercise in helping corporate America make more money, while taking valuable time away from me, my employer, my patients, and my family is an abomination and a manipulation,"

    You nailed it here. Any cost that can be off loaded onto another, will be, even inside the organization. There are managers that never cease trying to outdo each other with their mind-numbing, empire building, cost-saving, profit-building plots and the number-crunchers that support them, ad infinitum in the business world. Funny thing is though, they never include what I call the "soft-costs" in their calculations. And, certainly never the human costs. A process or policy could be costing the business money, but if it looks good on the spreadsheet, all is well. And, the pride of ownership of this faulty thinking is really something to behold when managers brag about how well they are running things.

    Here is an alternate PBM line, a bit more cynical or maybe just closer to their true thinking: "We will stop at nothing in getting you to pay us more each year and we are under no obligation to provide you with anything in return."

    Can you tell I worked in Corporate America?

    1. Sounds to me like the "Wolf of Wall Street". Contempt for the consumer/patient and any medical personnel unlucky to be trying to help them. I know exactly what your mean about cost shifting as acceptable management. I have seen all kinds of shifting justified by "cost center" methodology including one neat trick where some staff members were supposed to cover the salary of others with their "productivity". You can always make a profit by shifting costs to the employees and the customers.

      And then after all is said and done advertise it as "cost effectiveness" or some other buzzword.

  2. In keeping with the "What's good for business" theme I encourage a look at a recent APA document analyzed by PsychPractice at:

    Apparently the people who commissioned the report can't interpret what it really means for business. They think it will actually be good for psychiatry! Instead it is a recipe for the complete marginalization and extinction of the field.

  3. I agree very much with your post. As an "out-of-network provider" I often remind myself that I have no business relationship whatsoever with health plans or PBMs; I don't owe them a thing. I only put up with their calls and faxes as a favor to my patients, to help them receive benefits they, or their employers, already paid for. These companies bank on — exploit — our dedication to our patients. Yet they use our time and goodwill to deny benefits to those very same patients and, in your words, help corporate America make more money. How can we opt out of this insidious game without harming our patients?

    1. Steven,

      I agree with you and the documented extent that they are ripping us off is huge. Even if you can maintain your productivity by working more - that is all unreimbursed time permanently stolen from you and your family. The physician offered solutions to this are so weak and compromised that they are embarrassing. As the president of our local chapter, I listened to reasons why the best we could hope for was a standardized form to fax back to PBMs. Nobody told me at the time I would be expected to call back all of the pharmacies as well.

      Guess what - nobody is sending me that form that our local society advocated for. They are engaging me in their manipulative schemes to waste my time and basically make money by that manipulation.

      The business takeover of American medicine continues to be one long and very dark chapter. It is amazing how fairly bright people can allow themselves to be pushed around like this without a fight. I have had a number of theories over the years and my current one is that there are not enough physicians with blue collar roots and an intense skepticism of anybody with power. My father was a forced union man. He had to join the union in order to work. He didn't trust the people running the business or the people running the union to look out for his best interests.

      By contrast our "union" is trusting a pro-managed care consulting firm to tell us how we will all be rich by sharing the collaborative care dividend. There is a blue collar term for people with that belief system that is synonymous with " person who is easily cheated, deceived, or imposed upon."

      If you act like a loser - you get treated like one.

    2. I had a "fun" one today. Patient takes generic bupropion xl 300mg daily, but the pharmacy is back-ordered and they requested I order 150 mg tabs, 2 daily instead. Fine, no problem. Ah, but doctor, this requires a prior authorization! You're kidding, right? It's your problem, not mine, I didn't even change the dose.

      Nope, it IS my problem, if I want the PBM to pay for my patient to keep taking her stable dose of medication. So I succumbed... 15 minutes out of my life.

  4. Dr. Dawson, I see you are coming around to my view of APA/AMA vs. hospital/mangled care/politicians/insurance/ABMS as Dick Van Patten at the OK Corral. There is a time and a place to be a mensch but that approach has led to nothing but trouble for medicine. Do we stay the course or take the AAPS approach and fight? Or keep voting for out of touch academics with tenure who heart Obamacare/mangled care/MOC to lead us over a cliff?

    1. I have complained so much about the APA process that one of the recent presidents suggested that we talk. The reality is that the APA structure is set up to be self propagating unless there is a high degree of activism. I think the only activism I have seen mustered lately was the failed MOC petition that lost on a technicality. Historically the organization has only managed about 1 year of activism per issue and as Harold Eist illustrated - that is not nearly enough to fight the business cartel.

      The problem is that we have never fought and now it seems like there are too many fronts. The most urgent one I feel is MOC/MOL because once again we have a purely arbitrary decision made by people with a huge conflict of interest and no evidence that generation of physicians will be cursed by. It will only implode when it has become obvious to everyone that physicians may look reasonable on paper but that they are basically doing the bidding of the managed care cartel or whatever they invent themselves as in the future. If the AAPS can fight and win that it will be a real victory that they can potentially build upon.

      But I do think there is the previously stated cultural element. Without the blue collar attitude - there is a tendency to trust in institutions and structures. It should be evident that both the APA and the AMA have failed their membership and now seem to be adding to the problem.

  5. So basically, it's an ineffective glee club. Should we give them money or redirect the money to the AAPS who is fighting the good fight against MOC? (Disclosure: I have not been an APA/AMA member in three decades and I recently joined AAPS.)

    1. I would say direct the money to the people fighting the good fight with this provision - you never quite know what happens to the money during a political fight. I can recall hearing a story from a reliable source about how physician lobbyists were sat down one day on the Hill and basically told to shut up and listen. They were advised that they could sit in the room but would not be taken seriously. This was from a political battle that occurred many years ago but it explains why members of physician professional organizations have had practically no political influence for the millions of dollars sent to Washington by their members. I have not seen an analysis, but the managed acre cartel and the pharmaceutical industry has much more influence for about the same amount of money or less.

      If it was up to me - I would not send a dime to Washington and fight it out in public opinion by pointing out how any medicine that originates there is bad medicine. You can't really fight them by handing them your wallet and going along with anything they want to do.

  6. The response to shut and listen is to walk out of the room and tell your members what just happened. If you tell the teacher's union head to shut up and listen, there will be a strike.

    BTW, there seems to be plenty of money in Obamacare if you are well-connected. It's just how things work in the kleptocracy.

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