Elaine Siegfried, M.D., is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis, Mo. She also is a member of the Dermatology Times Editorial Advisory board and a co-medical editor.
The Prior Authorizations process creates inconsistent application, physician dissatisfaction and opportunity for life-threatening adverse events for patients.
The intended consequence of Prior Authorizations (PAs) is to minimize use of expensive, risky, and inappropriately prescribed medications. Some therapeutic categories have benefitted from this intervention, most notably inpatient antibiotic stewardship. But when broadly applied, most of the policies are about cost, masquerading as safety, resulting in delayed or restricted access to recommended medications, and no comparable alternatives.
The PA process has definitely compromised my ability to treat patients. PAs are now required for the majority of drugs I prescribe, using dumbed-down rationale, most often derived from FDA labelling and inconsistently applied.
Elidel, for example, is FDA-approved for children down to age 2, but access often requires a PA. On the other hand, betamethasone ointment labelling indicates use for only those over age 13, but is readily filled, without question, for infants. Access to newer drugs, like those for itch is denied for many patients. The intrusion of PAs on the physician-patient relationship has surpassed electronic medical records as the leading cause of physician dissatisfaction. A December 2018 American Medical Association survey completed by 1,000 physicians corroborated this impression. The great majority reported that the burden increased over the last five years to “high” or “extremely high,” and has negatively impacted patient outcomes.
Almost one third reported that associated delays lead to serious or life-threatening adverse events for patients. These physicians and their staff spent an average of two business days per week on PAs and over one third have staff members whose time is exclusively spent on this task.
My son was one of those staff members for two years when he worked in a general internist’s office. He was hired as a scribe but took over PA responsibilities because medical training and experience were not required, and the task was so frustrating and time-consuming for the clinicians.
Delegating PAs to low-paid employees may be the path-of-least resistance, but it also enables perpetuation of this meaningless exercise. My son and my own staff have spent hours struggling with poorly designed platforms unable to access patient information and waiting on-hold during phone calls to speak with equally untrained and inexperienced payor representatives. In the internist’s office, denials were common for life-saving drugs like insulin. In my office, PAs impact almost all prescriptions I write, from acne to severe inflammatory skin disease. In an attempt to understand and address this issue, we recently reviewed the reasons for our denials.
Age younger than that indicated on the drug label was the most common. Our attorney collaborators found a clause in the Affordable Care Act that bans treatment-related age discrimination, prompting the following statement in my appeal letters: “Restricting access to the medication on the basis of its FDA-approved indication does not excuse the fact that this practice constitutes illegal age discrimination in clear violation of section 1557 of the Affordable Care Act.”
Other reasons for denials applicable to patients seen in a general dermatology practice, is to enforce step-edit requirements or restrict a drug prescribed off-label. My appeal for these decisions includes: “Your attempt to enforce your general criteria without regard to the extenuating factors in this case is essentially the practice of medicine by an organization, which is illegal in several states.”
I also frequently request a peer-to-peer review and inform the reviewer that their name and credentials will be documented in the medical record. Although involving the patient in the PA process is a good idea in theory, neither my office, nor my son’s employer routinely does this, because health literacy in the general population does not support the success of that strategy.
The evolving practice of medicine has always faced obstacles. In the 1980s, dissatisfaction stemmed from the new gatekeeper-controlled, managed care model. Computers were changing the acquisition of information and the physician-dominant power structure was beginning to falter. These menaces have been replaced by electronic data entry, PAs and the consolidation and corporatization of medicine. But medicine remains a great career with relative autonomy, respectable peers and a focus on service to others.
The practice of medicine will continue to evolve, and, hopefully, improve with intelligent voice recognition software that will be able to record beyond verbatim, actually taking notes and learning along the way. One day we will have a system that incentivizes prevention, rewards efficiency and measures true long-term health outcomes.
I strive for a glass-half-full world view and try to make lemonade from bitter lemons. So, it occurred to me that a benefit of the PA process is to provide opportunity for experience and a path to medical school for a growing army of medical scribes, including my son, who was not dissuaded by the work. As a first year of medical student, he is looking forward to a rewarding career.
1. 2018 AMA Prior Authorization (PA) Physician Survey. American Medical Association website: https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Accessed September 2019.