MCMS Physician Fall 2017 - 17

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nsurance companies say they use prior authorization to
prevent physicians from prescribing too much medication
or ordering too many tests. But physicians say the use
of prior auth has grown out of control - and few stories
illustrate it better than that of Joe Stanziano.
Stanziano, who currently resides in Montgomery County (Pa.),
owned a bakery in New Jersey. Ten years of carrying heavy bags of
flour and working 18-hour days took a toll on his back.
Stanziano had just undergone his fourth back surgery in five
years and was taking pain medication to help with his recovery.
Things were progressing well enough for Stanziano to begin
taking a smaller dose of the pain medication - a process known
as tapering that could eventually allow him to wean off the
medication altogether.
The problem is, Stanziano's insurance company denied
payment of the lower dosage that his neurologist prescribed.
Hours turned into days and Stanziano continued to wait for his
insurance company's approval.
When his current allotment of pain medicine ran out, the
withdrawal symptoms began.
"Cold sweats. Shaking. You don't have control," Stanziano
described.
This wasn't a one-time mistake by his insurance company.
Stanziano's neurologist prescribed a lower dose of pain
medication five times. It was denied five times for up to a week
before it was approved.
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 - pre-certs
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:
* 86 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.

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