Prior Authorizations Suck

"Suck" is a word I seldom use. It's a word I ask my children not to use.  However, in this case the word is appropriate. If as a patient, you have ever had a delay in getting a medication or a test your doctor ordered, it was probably due to a prior authorization.  A prior authorization is a bureaucratic hurdle (sometimes a phone call, sometimes a fax, sometimes a letter) that is required by your physician to get you the test or treatment he or she believes is right for you. A prior authorization is essentially a mechanism that insurance companies put in place to make ordering more expensive tests or medications more difficult for you to get. The decision maker on the insurance company's end who decides whether your doctor (regardless of specialty or years in practice) is justified in requesting the medication or test that your insurance company is obligated to provide for you is often a 20-something college grad with no clinical experience.  Prior authorizations are probably one of the most frustrating things about being a primary care physician. 


I am far from alone in this opinion.  My medical society, The Medical Society of the District of Columbia or MSDC actually did a survey of their members examining the impact of health insurance prior authorization protocols on patient care in Washington, D.C. The study reveals widespread concern among area physicians, with over 93% of respondents saying that insurance company requirements are having a negative impact on their ability to treat patients.

In their press release,  Dr. James Cobey, President of MSDC stated that “Doctors, not insurance companies, know best how to care for their patients, yet prior authorization and other insurer protocols are dictating how physicians provide treatment. Prior authorization requirements put D.C. patients at risk by causing unnecessary and potentially dangerous delays for medications and care while preventing doctors from providing the most appropriate forms of treatment.”


Specific findings of the MSDC survey include:  

• 93.1%  of D.C. physicians surveyed said that insurance company requirements such as prior authorization, pre-certification, therapeutic switching, and step therapy are having a negative impact on their ability to treat patients;

• Nearly 90% of those surveyed said that they have been forced to change the way they treated a patient, including changing prescription medications, due to restrictions imposed by an insurance company;

• Over 76% of physicians also reported that they have switched treatments in order to avoid dealing with prior authorization requirements;

• 94.8% of physicians surveyed said that insurance companies have delayed or denied treatments for their patients, such as prescription medications, diagnostic testing, or other services;

• 84.6% of physicians said that is it difficult to determine which prescription drugs or medical procedures require prior authorization;

• About half (47.2%) of MSDC members surveyed said that on average, prior authorization requests take several days or more to be resolved;

• 89.7% of respondents confirmed that completing and clarifying insurance requirements imposes “hidden” costs—such as extra staff time for the additional paperwork and phone calls—that have a negative impact on their medical practice.

Folks at the MSDC are trying to get laws passed to implement a standardized system across the District, with uniform requirements for filing and processing prior authorization requests which would expedite this onerous process and allow doctors to finally focus on what really matters—treating patients. Every medical society should follow their lead. 

FDA Announces End for CFC-Propelled Inhalers

As reported in Med Page Today, the FDA Announces End for CFC-Propelled Inhalers. Of the seven inhalers with deadlines for removal, only three are still being made:

Flunisolide (Aerobid Inhaler System) on June 30, 2011
Albuterol and ipratropium combination (Combivent Inhalation Aerosol) on Dec. 31, 2013
Pirbuterol (Maxair Autohaler) on Dec. 31, 2013

The reason for this is because CFC's are harmful for the environment, and the newer inahlers have to be replaced with a different, more environmentally friendly propellant called hydroflouroalkane or HFA. I have blogged about this previosuly (please see Asthma inhalers and More on Asthma Inhalers ).

According to the FDA, "patients using the inhalers scheduled to be phased out should talk to their health care professional about switching to one of several alternative treatments currently available. Until then, patients should continue using their current inhaler medication."

What you should do:
1. Albuterol If you are taking albuterol, please see my earlier posts. I still have patients that have their very old albuterol canisters, which are probably no longer effective. An important thing to know is that there is no longer any generic albuterol. More importanly, if your physician writes a prescription for albuterol, the pharmacist will likely give you ProAir, which may or may not be what your insurance prefers and/or what is least expensive for you. This is because many of the chain pharmacies are getting a kick back from the makers of ProAir. Make sure your provider writes for the correct inhaler. All things being equal (same co-pay for patients), I recommend Ventolin HFA (because it is the only one with a dose counter) or Xopenex HFA, because of diminished side effects. NEW INFORMATION: GSK, makers of Ventolin HFA sell a $9 inhaler, regardless of your insurance. Though the inhaler has fewer puffs in it, if you are using your inhaler that frequently, then your asthma is not under good control, and you should be on a different controller medication. Ask your doctor for Ventolin HFA 60 (they have to write the 60 part).

2. Maxair- Some patients love this drug, but it's going away. Before January 2014, get another albuterol. See above and previous posts for advice.

3. Aerobid- I didn't even realize they still made this medication. It is no more effective then other similar medications, probably less effective, possibly more side effects, and it tastes nasty. If you are on this medication, switch ASAP to another inhaled steroid. Good alternatives include Flovent, Pulmicort, Asmanex, and Alvesco.

4. Combivent- This will likely affect patients the most, since few patients are on Maxair or Aerobid, and there are far more COPD patients than asthmatics. It is very likely that before January, 2014, the makers of Combivent with come out with a Combivent HFA. However, there are reasons to consider switching now. Please see older posts Good News for COPD , Bad news for COPD: Why this meta-analysis should be believed (and the Avandia one should not) , and UPLIFTing News for COPD

Briefly, a few studies have come out which make me very concerned about using Combivent. One study published in the Annals of Internal Medicine studied a VA population and found that patients taking ipratropium had significantly higher death rate of about 11%. A second study was a meta-analysis published in JAMA that analysed date from 14,783 patients with COPD and found that patients taking either ipratropium or tiotropium (Spiriva) or both had a 58% increase in cardiovascular death, heart attack or stroke when compared to patients taking other meds (Advair, albuterol or placebo). Though combined, these studies might cause safety concerns with the entire class of anti-cholinergic inhalers, the UPLIFT trial, a long-term, large randomized controlled trial (4 years, almost 6000 patients) which unfortunately failed to show that Spiriva could decrease that rate of lung function decline, did show about 10% relatively fewer deaths. Thus, though anti-cholinergic medicines may cause some harm, it appears that this is likely mainly for the short acting ipratropium and not for the long acting tiotropium. I would therefore recommend that COPD patients talk to their doctors about stopping their Combivent now and switch to a different controller medication (Advair, Symbicort, Spiriva) and/or switch to albuterol alone as a rescure medication.

Having health insurance doesn't ensure it will be easy to find a doctor

An excellent article appears in today's Washington Post entitled "Having health insurance doesn't ensure it will be easy to find a doctor," where a young, otherwise healthy and insured woman discusses her extreme difficulty in finding a doctor in Washington, DC who will see her.

"I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of pre-approved doctors and started calling. And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.) "

Next to Massachusetts, D.C. has the largest number of physicians per patients. (The article briefly mentions the lessons Massachusetts has learned about providing health care for everyone without addressing whether there are enough primary care physicians to see them). D.C.'s doctor excess, like Mass., is somewhat exaggerated given that there are several teaching hospitals with more than a few resident physicians. However, there are more than enough docs in D.C. to see patients. The problem is that in addition to not having enough primary care physicians, more and more primary care physicians are not accepting new patients. The article suggests that this is a supply and demand issue, which is true. However, another major factor that the article neglects to mention is that there are many primary care physicians in D.C. gladly accepting new patients. However, they will not take your insurance.

I practice in a large, academic teaching center in D.C. and we stopped taking new patients several years ago. This happened because many of the physicians in D.C. stopped taking insurance, and many of their former patients who were not willing to pay out of pocket to see their former doctor came to our practice (we take virtually every insurance). The problem is that we now have so many patients, they have a very difficult time getting to see us for an appointment.

The article suggests several solutions to increase the number of primary care physicians including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care. These are good ideas but will not solve the problem. In a survey we did, we found that only 2% of students going into internal medicine were going into primary care internal medicine. The main reason that they chose not to do primary care was lifestyle. Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society. Until this problem is fixed, the primary care crisis will remain. ( See Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them! )

I have previously discussed that the same issue happened with psychiatrists years ago, and this is why we have a two types of psychiatry in the US. The psychiatry that you see on the TV and in the movies only occurs for those patients willing to pay out of pocket for their care. Those who pay for mental health with insurance might see a psychiatrist once a year for a few minutes, but any counselling is done by someone else. Getting an appointment with a mental health professional that accepts your insurance is similarly challenging. (See a piece I wrote for KevinMD called "As psychiatry goes, so will primary care," and How can a psychiatrist write 100,000 prescriptions a year, and why this matters to Primary Care? )

Though I believe it is important to support health care reform, it will do nothing to fix the lack of primary care physicians nor does it address the root cause of the problem (see Why you must support health care reform, even though it won't fix our health care system. ). If you are frustrated by the system, one thing to think about is paying out of pocket to see your primary care physician. Though many doctors who see "cash paying" patients run more of boutique or concierge practice, more and more primary care physicians are seeing patients at more reasonable prices, and just desire to get the insurance middle man out of the picture ( see Insurance Free Medicine )

Update: A related post byDr. Toni Brayer was just posted on KevinMd. Primary care needs to be valued first before it can be saved . I think a lot of us are all saying the same thing.

Insurance Free Medicine

I never thought I would be in academic medicine for so long. When I was hired about 12 year ago, I figured I would stay in academics for a few years and then join a private practice Internal Medicine group. Now, I can't even fathom that idea. One of the reasons I have stayed at my institution for so long is that I love teaching and the academic environment. However, a second reason is that the "real world" for primary care medicine is a scary one. As a salaried employee in a large practice, I am somewhat sheltered from the harsh realities of running a business in the current health care environment. Yet, I hear horror stories from my colleagues in the community that are struggling to survive. With reimbursement rates from insurances so low, and administrative burdens so high, many older physicians have retired and younger physicians have adopted new models of delivering care. These have various names such as "concierge medicine" or "boutique practices".

Though I have no intention of leaving any time soon, I know that (assuming there are not major changes via health care reform) the current model of a small group of primary care physicians who accept insurance is simply not sustainable. Yet, I have a hard time imagining myself practicing in one of these new models, or even attracting patients to my practice. Retainer medicine is one model, where primary care physicians are able to see a much smaller panel size (and thus increase access) by charging patients an annual fee, which ranges from hundreds to thousands of dollars. Though the model makes financial sense, the word "retainer" sounds too legalese for me and likely not easily understood by the lay public. I would prefer something like "membership fee" similar to something would pay to join a club. However, "membership medicine" or "club medicine" just doesn't seem to have a good ring.

"Boutique" practices often use a retainer model, but boutique can also refer to primary care physicians who charge for extra services such as laser hair removal or botox injections. There are many primary care physicians who still take insurance that have started using these kind of practices or have found other ways to meet their bottom line, such as selling nutritional supplements. Though there is no question that the public has a demand for these services, providing them for a fee as a primary care physician seems to carry some conflict of interest, since none of these services show any benefit in overall health. "Concierge medicine" is another term used with retainer models and boutique practices. This implies some sort of preferential treatment, but also usually is associated with "executive physicals" and a battery of unnecessary testing and high technology that again provides little in the way of proven health benefits.

Some physicians have continued to practice normally, but simply do not accept insurance. They have figured out that they can sustain a primary care practice if they simply refuse to accept the substantially reduced rates that insurance companies give them. These are often referred to as cash only practices. Yet, the term "cash only" seems to imply (at least to me) something shady or under the table. In addition, most patients who see cash only physicians, pay for these services using a credit card, making the name somewhat illogical.

However, the reason that all these new models of medicine exist boils down to one single reason: health insurance. Rates from insurance companies are so low, that the only way a primary care physician can make ends meet is to increase volume to the point that both access and care delivery suffer substantially. In addition, the administrative headaches which include fighting to get tests/medicines covered and arguing over claims once submitted, make the practice of medicine less than enjoyable. The often quoted study (that I co-authored) showing that only 2% of medical students are interested in primary care internal medicine, is often used to support the argument that primary care physicians need to be paid more. While the need to substantially reduce the growing income discrepancy between primary care physicians and specialists is critically important, the study actually showed that educational experience, nature of patient care and lifestyle were the primary factors influencing career choice, not income. This was regardless of students' medical school debt. In other words, it was more about the hassles of primary care medicine and less about the how much money they would make, that led students away from careers in primary care.

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care (in blogs, media, etc.) is "insurance free medicine." In my opinion, the term "insurance free medicine" captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance. Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like "boutique," "concierge," and "cash only" might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. In a previous post on KevinMD, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies. With a more frequent use of the term "insurance free medicine," patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

Though I have no immediate plans to leave the world of academia any time soon, I could certainly see starting an insurance-free practice if I ever did.