Shirah Vollmer MD

The Musings of Dr. Vollmer

Prior Authorizations

Posted by Dr. Vollmer on January 12, 2015

I write a prescription. The pharmacist says “it can’t be filled”. I say, “you mean that insurance won’t pay. That is not the same as ‘it can’t be filled.'””Yes, the patient can pay for it out of pocket, but it is expensive,” the pharmacist says. What does expensive mean, I wonder to myself. That is such a relative term. What should people pay for medications, if they have insurance or if they do not? Isn’t this more about patient expectations than denying my prescription? “Well, if you fill out a prior authorization, then maybe they can get it approved,” the pharmacist explains to me. Please explain this to me, I want to say. How and why do insurance companies have the ability to decide whether or not to pay for the prescription? Since when have insurance companies become physicians, with the ability to judge whether or not a patient needs a particular medication? I know that with auto insurance or home insurance, there are adjusters which determine the damage, but they rely on expert opinions. Who are the “experts”? Physicians employed by insurance companies who are paid to minimize expenditures. This is not making sense, and yet, I fill out the prior authorization in an effort to aid in the “expense” only to be told that the insurance company has denied my request. Am I supposed to change my mind about which drug to write for? Should I write for a drug which is my second choice because the insurance company will have better reimbursement? These are daily ethical dilemmas that my colleagues and I struggle with.

Historically speaking, when I started in my practice, in 1990, there were fewer “prior authorizations”.  The trend has increased for reasons which may have to do with more people having insurance, resulting in insurance companies needing to cut more corners. Regardless, the prior authorizations confuse patients and physicians. If insurance companies would either pay or not pay for prescriptions, then patients would know what to expect when they go to the pharmacy. Instead, there is sticker shock, followed by hope of an appeal, with a chance for reimbursement, but at the same time, delaying the start of treatment. This brings us to the issue of the drug companies charging exorbitant sums for medication, which is only true in the United States, and the complicated politics around that. That rant is for another time. This rant focuses on the shrinking autonomy of physicians, and the increasing ethical dilemmas which result from that. Despite the fact that my practice does not bill insurance directly, the fact that I write prescriptions weaves me into matrix of Big Data guiding the course of treatment. Big Data works for population health, so for controlling cholesterol and blood pressure, that data is useful, but I work with individuals, and my primary concern focuses on individuals, not populations. Therein lies my historical relevance, since at the end of the day, people care about themselves and their family and friends before they care about populations. That fact keeps me going.

4 Responses to “Prior Authorizations”

  1. Jon said

    First, welcome back and Happy 2015!

    Now to comment upon your rant, err… post. As you well know, it is sad when a bureaucratic mandate thwarts the right and true desires of an expert. It is even more poignant when you are that expert. In this case, the mandate is clearly and simply economic in motivation. The combined ghosts of Hippocates and Freud must be spinning in their graves. Since the inner workings of human mind is much more complicated than the control of human cholesterol or blood pressure, it is understandable that your “primary concern focuses on individuals, not populations. Therein lies” not just your historical relevance but the entire art and science of your well-practiced disciple. Keep on going!

  2. Shelly said

    Glad to have you back, Shirah.

    If one pharmacy won’t fill a prescription because of insurance, does it mean that the next pharmacy will also deny it? Can the patient pay for it out of pocket if he so desires? Is there a generic equivalent? Is the denial because there is some medication which is the same but cheaper, and that is why the insurance company isn’t paying? I understand completely your frustration. Please let me correct one sentence from this post: “This brings us to the issue of the drug companies charging exorbitant sums for medication, which is only true in the United States, and the complicated politics around that.” Where I live, if the prescribed medication is not covered by the health plan, we pay out of pocket. Period. And because of some of the exorbitant prices of these out of pocket meds, I’ve simply stopped buying the prescribed meds. When asked by my doctor why I didn’t fill my prescriptions, I simply stated that I couldn’t afford to pay for them because they were not covered. So, it seems, Big Brother follows us everywhere, and not just in the US.

    • Thanks, Shelly.

      Yes, the patient can pay out of pocket, but the prices are exorbitant. There are generics, but the generics are also very expensive and they also require prior authorizations. No, the insurance company does not offer alternatives, but even if they did, I am aware of the alternatives and so there is a reason I picked the one I did.

      Thank you for the correction. It was my understanding that medications are considerably more expensive in the US than in other countries, but you have inspired me to drill down and get more details about that.

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