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.