Prior Authorizations

[anonymous]

Dr. Dave,

In today's market Prior Authorizations for a branded product are very common. I have one product in my bag that has decent coverage, however one major insurance carrier has a Prior Authorization. Basically it requires a failure of a commonly used over the counter product, meaning they just have to try it for a couple days and not achieve what the doctor feels is an acceptable result. If they document that in the chart and fill out the prior authorization form, my accounts tell me they get very little push back from the insurance company.
I don't push the issue too often with my accounts. I focus on the other insurances that cover the product and when asked, I tell them that the patient has to try the other product first. Some accounts will do the authorization and some will not.
I guess it's just being an older rep, but one thing that is really starting to bother me is this snarky response of "well, what do you think we have time to sit around and fill out these forms all day? I mean if I take three or four minutes for to do that for each and every patient...I don't have time for that...I'm way too busy. I am not going to do that."
I usually try to diffuse the situation and say that I am not asking you to fill out the paperwork. I am just explaining what needs to be done and then refocus on the other insurances where access is not an issue.
I get it that offices today are busy, more patients, more paperwork, etc..
But I guess what bothers me is that if a patient tries the over the counter product and doesn't get better...then what? I ask them that question and they just the patient to keep using it and that's all there is...but the clinical literature supports using this product if the over the counter fails...(which I have shared with them on numerous occasions)
Somedays I feel like responding to them and saying "So, do you tell your patients there's another product out there that might help them, but you don't want to fill out a piece of paper because you don't have 5 minutes?"
Dr. Dave - Am I way off base here? I always try to remain professional and not go there, but if the patient's not getting better...this is really starting to get to me...thanks

 

[DrDave]

I might be able to give you a better answer if I knew your product, but in general terms-

You are technically correct, but the term "prior authorization" (PA) brings up a lot of experience and baggage on the part of physicians. I think (hope) most of us would take the time to do one if there is truly no other alternative, but, as you know, that is often not the case. For example, if I start a patient on one generic PPI and get a PA request from the pharmacy, I'll try at least one or two others before I go through the PA process. There is a very broad spectrum between a drug being needed, preferred or merely a reasonable choice among others. If the physicians you call on feel your product is closer to the latter, they are likely to try something else first.

Just to take you through, from my end, the PA process goes something like this:

-I send the rx to the pharmacy;
-Pharmacy notifies me that PA required and gives me the contact info (about 15% of the time, they give me the incorrect insurance information and I wind up doing the PA steps below twice);
-My nursing staff enters the pertinent information in CoverMyMeds (note-if your customers don't know about CoverMyMeds, you could do them a huge favor by educating them, and it may help your sales);
-I log in and 1) complete and submit the form OR 2) Find that I need more historical information and contact the patient OR 3) derive from the information on the form that there is no chance of approval and abort the process;
-Once submitted, I have probably 80% chance of success (remember, I don't submit forms that I feel certain will be denied); IE, about 1/5 are wasted effort.

There is also a lot of corollary frustration with PAs. For example, yesterday I was asked to do a PA for same drug (already approved in the past), different dose. Conversely, rolled into that success number above are some prescriptions that actually did not need PA (the pharmacy was incorrect), but I didn't find out until the process was done. Sometimes the pharmacy asks for a PA when the cash price is very affordable but they don't relay that to the patient.

Of course, PAs do not guarantee a reasonable out of pocket cost, only some degree of coverage. I have done PAs in the past only to have the patients decline the drug because the cost is still too high.

Also, PA's expire, so it's not just a one time process for most chronic meds. Every 6-12 months, I'm doing it all over again.

In a nutshell, will I make the effort if I think a drug is necessary or even significantly better than others? Of course. What I'm reading into the response you're getting is that your physicians think they have other reasonable choices or are skeptical of your drug's value. If I'm going to put that much work into a prescription, I have to believe in it.

I hope that helps some. Thanks for your post!

 

[anonymous]

PAs are tough. Once a physician has had to do one or two for your drug, even if it is only for one insurer, it seems that the physician begins to think of your drug only as a last resort. I think most Drs are just so busy they don't really have time to stop and think which drug requires a PA from which carrier.

Some Drs (like Dr Dave) will do them when necessary, but I think a lot will avoid them if there is a reasonable alternative. I do hope that most would take the time if there truly was no other alternative though. The problem is too often that there is an alternative, but the alternative is not as effective, has unpleasant side effects, etc

 

[anonymous]

Unfortunately, most physicians practice bad medicine and would rather not take the time to do a PA. Just the fact that it is an issue proves that. PA's are generally the first issue they bring up about a product. Not its efficacy, safety or tolerability. They should take the time to learn about the new meds, determine if the patients needs it and if they do then complete the darn PA. If a relative needed a medication and their doctor used a medication because he did want to do a PA how would they feel? It's embarrassing that there are so many doctors and hospitals that shun the pharmaceutical reps/industry but don't know the basic information necessary to optimally treat patients. I've talked to doctors, specialists in their field (psychiatrists), about a med that they didn't even know existed, but has been on the market for over two years. Even if they don't want to meet with reps they should at least read a journal or two. The bottom line is that doctors are down right lazy and bitter!

 

[DrDave]

PA's are generally the first issue they bring up about a product. Not its efficacy, safety or tolerability. They should take the time to learn about the new meds, determine if the patients needs it and if they do then complete the darn PA.

This is a fair point. However, price (usually directly proportional to PA requirements) matters as well.

It sounds like your perceptions are unlikely to be swayed by my comments, but, for the sake of providing a counterpoint for those observing the exchange-

Based on my review of Covermymeds year-to-date, I have 144 prior authorizations on file for 2015 (probably 85% of the authorizations I do, others are via fax or phone, so I'm guessing the real number is around 160-165). I have colleagues here that have many more than I do. I'm not sure if there is a number that pushes me above the "lazy" benchmark, but budgeting the time for those during busy clinic days continues to be challenging. Yet, I still do it.

The bottom line is that doctors are down right lazy and bitter!

Yes, sadly, some are bitter; I think fewer are lazy. Most are just trying to navigate a health care landscape that changes at lightning speed as best they can with a great deal of struggle, at least where I am.