Lancaster Physician Fall 2017 - 23

FA L L 2 0 1 7

Prior Auth

As the delays grew longer and withdrawals
continued, Stanziano opted to buy the medication out of own pocket. Each pill cost $60.
"One could imagine a reason for (denying
it) if we're increasing the medication, but in
Joe's case we were gradually decreasing the
medication," said Daniel Skubick, MD, Stanziano's neurologist. "In spite of the fact that
we were doing the right thing (by lowering
his dosage)-getting him off opioids-precerts would still be coming."
Stanziano said he was never given a clear
answer as to why his medication decrease
required a prior authorization.
"You could talk to two different people (at
the insurance company) in the same day and
get two different answers," he said. "Explain to
me the logic-why are you denying it when
we were trying to reduce (the medication)?
Does it make sense to you?"
"Are you trying to cut costs, or are you
trying to cut lives?" Stanziano continued. "I
can understand trying to cut costs, but put
them in my situation. Let them be on the
medication for a certain period of time, and
not be able to refill it, and have to go through
what I went through."

PRIOR AUTHS ON THE RISE

Physicians have seen a dramatic rise in prior
authorizations over the past few years for a
variety of treatments and medications:
Eighty-six percent of respondents to a Medical
Group Management Association survey said that
they experienced an increase in the number of
prior authorizations over the past year.
Medical practices average 37 prior authorizations per week, per physician (taking
up an average of 16 hours per physician),
according to a survey from the American
Medical Association.
A few years ago, "If a narcotic that we're
prescribing was thought to be at a very high

dose, you might have a pre-cert," Dr. Skubick
said. "But the prior auth would last 6-12
months, and it might occur occasionally.
Now, over the last few years or so, fueled by
the opioid crisis, we're running into pre-certs
whenever a change is made to the medication."
The delays are proving costly to patients.
Here are just two more examples:
Pittsburgh's Jeff Duncan waited eight
months for approval on an in-lab sleep study
that he needed in order to receive treatment
for his severe sleep disorder.
"What if I would have died with this?" he
said. "Personally, I'm just irritated that the
insurance companies have so much power
over doctors trying to get their patients what
they need."
Pittsburgh's Kristen O'Toole experienced
delays in getting an MRI for her back pain.
The weeks' long wait allowed her undiagnosed
multiple sclerosis to progress, and she is now
in a wheelchair.
"If I had gotten the MRI earlier and started
on the infusions, I really believe it could have
kept some of these symptoms at bay," O'Toole
said. "Maybe I would have never ended up
in a wheel chair."
"The doctor knows there's a problem here,"
O'Toole added. "There's something going on.
And how is he going to know before he gets
the data from the MRI?"

"But I'm talking to people (at the insurance
companies) who are not even doctors some
of the time. And sometimes when you do
get a doctor, you're getting an internist or
a gynecologist-what do they know about
neurology? What do they know about the
subtleties about whether an MRI is necessary?"

PHYSICIANS MUST BE PART OF THE
SOLUTION

Oncologist Rick Boulay, MD, wrote a
recent blog post for KevinMD: "Most patients
are unaware of this, but your physician is
likely your biggest advocate when it comes
to getting your care covered."
Similarly, physicians need to step up to support new legislation in Pennsylvania that aims
to decrease patient wait times from prior auth.

HOUSE BILL 1293, INTRODUCED
BY REP. MARGUERITE QUINN
(R-BUCKS), WOULD:
Increase transparency and
consistency in prior authorization
criteria.


Establish standards for and
reducing the overuse of prior
authorization.


Lessen manual processes and
enhance the electronic exchange
of information.


Develop a standard prior
authorization form.


Dr. Skubick said his biggest frustration
with the rise of prior authorizations is that
it takes the clinical decision-making out of
the hands of physicians.
"I think it is incredible that the insurance
company would think that a person who has
practiced neurology for 35, 40 years doesn't know
more than somebody on the other end without
seeing the patient," he said. "I've never had a precert denied for any diagnostic study when I'm
able to talk to a colleague that is a neurologist."

The Pennsylvania Medical Society and
its coalition of 50+ physician and patient
advocacy organizations support HB 1293.
But this legislation will only move with a
strong grassroots effort from physicians,
medical office personnel, and patients.
Continued on page 24

SEE HOW YOU CAN GET INVOLVED BY GOING TO THE PAMED WEBSITE,
WWW.PAMEDSOC.ORG/PRIORAUTH.
LANCASTER

23

PHYSICIAN


http://WWW.PAMEDSOC.ORG/PRIORAUTH

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