The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.”
Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their dosage limits are. And if it isn’t a covered drug, the covered alternatives are usually not listed.
So the insurance company is hoping for one of a few possible reactions to their fax: The patient gives up, the doctor tries but fails in getting approval, or the doctor doesn’t even try. In either case, the insurance company doesn’t pay for the drug, keeps their premium and pays their CEO a bigger bonus.
First problem: This may be in regards to a medication that costs less than a medium sized pizza. And the pharmacy generally doesn’t even bother telling the patient what the cash price is.
Second problem: A primary care physician’s time is worth $7 per minute (we need to generate $300-400/hour). We could spend half an hour or all day on a prior authorization and there is absolutely zero reimbursement for it.
In my opinion it is unconscionable for an insurer to say a drug isn’t covered without listing the covered alternatives. They are truly making us play a game where only they know the rules – and I have seen some of them change the rules mid-game.
EMRs sometimes have functional formulary checkers built in, but they don’t always work (I’m talking about you, Greenway – again).
There are too many insurance companies for a provider to separately check their websites before prescribing.
There is an app called Epocrates that has some formularies built in. I have it set to Mainecare, the Maine version of Medicaid. But far from all insurers are included. Whether this is Epocrates’ fault or the insurers, I don’t know. All I know is I’m playing prescriber without knowing the rules of the game.
It is a pathetic state of affairs. The technology is out there but it isn’t in the interest of the for profit insurance companies to use it.
This alone is a reason to consider a one payer system: Mainecare publishes their formulary with real time updates and shares it with Epocrates. Their step care rules are easy to understand for both prescribers and patients.
Prior Authorization requirements are mostly meant to save insurers money, but sometimes they are efforts to control provider behavior. But we have the medical license and bear the liability burden when we prescribe. And the insurance companies don’t seem to have any legal risk when they refuse to honor our prescriptions and leave patients without treatment.
This situation is pure evil. I don’t think my analogy of playing poker with the devil is exaggerated at all. It is provider harassment and customer abuse.
A Country Doctor Writes: 
This is only one of many reasons I don’t take insurance anymore. I’m free.
But in many cases patients have already paid for “insurance”, maybe required at place of employment. Big deductible, catastrophic ins.?
Copy to you of earlier correspondence about the Medical Care Restoration Act. Hope you will read and evaluate. Remember the KISS system! Come visit on Dykers.com
Dear Dr. Kocher,
Thank you for such a thorough, insightful, and pointed analysis of the chaos that is driving us all crazy.
Following is a letter to colleagues who also understand.
Dear Dr. Steinbrook,
You and Drs. Katz and Redberg did a magnificent work in outlining the deficiencies and stresses of health care in America. Patients and physicians and payers are bamboozled by the chaos. The administrative leeches that siphon billions annually from the health care of Americans will steadily disappear with the Medical Care Restoration Act. Compared to M4a, the Medical Care Restoration Act is smoother, more effective, Voluntary, Universal, improves quality of care, decreases cost, moves economic power, authority and responsibility, to a Dr/Pt relationship which is healing, and away from hassle bureaucracy of government, insurance or hospital interfering with healing. MCRA diminishes defensive medicine, encourages learning, preventive medicine, and patient care; restores non monetary rewards to practice of medicine and surgery, requires physicians to earn their keep, restore honor, affection and effectiveness to the healing professions. MCRA text is 10 pages 5×7 and 16 font in Chapter 2 of “The Price of Eggs Is Down”. I think you will appreciate other chapters too.
I hope you will add your voice to permissive legislation that does not require repeal of ACA.
John R. Dykers, Jr. MD Dykers.com for CV and bio johndykersmd@dykers.com
This is one of many reasons why in 20 years community primary care physicians will be nearly extinct-Americans will access primary care via APRNs and PAs only.-APRNs are gradually becoming licensed independent practitioners. MDs and DOs will become specialists, subspecialists, “sub sub specialists”, or hospitalists and will be primarily hospital based. Specialty office practitioners will also be increasingly APRNs and PAs, We may have some pockets of primary care MD/DO Concierge Practices left though.
I feel your pain!
The answer is of course a single provider……as we have in Australia, and I think most other countries.
Medicare for medical payments to doctors, and the PBS for pharmaceuticals.
Actually we don’t have a single provider as we also have Veteran Affairs that funds all military personel and families……
I left Sweden in 1981 thinking they were too bureaucratic (plus I married an American girl). I’ve tempered my criticism of socialized medicine since then.