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February 3, 2020

Refocusing Medication Prior Authorization on Its Intended Purpose

Author Affiliations
  • 1Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
  • 2Department of Dermatology, School of Medicine, University of California, San Francisco
JAMA. 2020;323(8):703-704. doi:10.1001/jama.2019.21428

During the 1980s, prospective utilization review programs deployed by US health plans focused on screening the appropriateness of hospital admissions and high-cost procedures. As prescription drug coverage became more widespread and spending on pharmaceuticals increased, commercial and public insurers expanded utilization management to include medication prior authorization, quantity and dosage limits, and step therapy requirements. Applied in concert with restricted formularies and tiered patient cost sharing, these measures were initially directed during the 1990s and early 2000s at a narrow set of newer, high-cost drugs that insurers judged to offer limited benefit or higher risk over existing, less expensive alternatives.

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    5 Comments for this article
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    Formulary Changes Lead to Many PA requests
    Jesse Hackell, MD | Boston Children’s Health Physicians
    Prior authorization (PA) requirements can serve some valid purposes, as discussed in this paper. However, one of the most troubling types occurs when a plan formulary is changed because the plan has negotiated new kickback/discount arrangements, which seems to happen every year. This requires NEW PA submissions even for patients long stable on therapies which have been approved in the past. Plans should be prohibited from requiring PAs for drugs which have been approved in the past simply for newly entered into financial schemes which only benefit the plan, and not the patient (or physician.)
    CONFLICT OF INTEREST: None Reported
    Inappropriate Coverage Denials are Medical Errors
    Thomas Morgan, MD | University
    In pediatrics, if a pharmacist or physician were to unreasonably interrupt a child's supply of essential, life-sustaining medication causing harm to the child, that would constitute professional malfeasance and serious consequences would ensue. If a parent who could afford to pay for a child's essential medication were to recklessly interrupt the supply causing harm to the child, there would be an inquiry into possible medical neglect, with serious potential consequences. What are the consequences when insurance companies and pharmacy benefits managers unreasonably and indifferently interrupt a child's medical supply by withholding payment, over the vehement objections of the physician, even when the parents are indigent? None. Needless and mindless threatening or interruption of the medication supplies of vulnerable children is done with impunity, all the time, as a matter of course.

    When insurers create bureaucratic authorization denial (BAD) pediatric emergencies, the pharmacy and children's hospital must rescue the child and supply, without payment, the medically necessary and appropriate treatments that were wrongfully denied approval. Such denials are almost always subsequently overturned on appeal, but not always in time to spare the child from some harm such as an emergency visit. Let insurers and pharmacy benefits managers deny that they would ever do such a thing. Let them agree with the premise that any such denials causing harm to a child would be wrong, actionable, and potentially criminal if motivated by avarice. Everyone else would surely agree with that premise, particularly if the parents are indigent and no robust due process and adequate grace period to make arrangements for charitable care are granted to the child prior to financial abandonment of the patient by the insurer.

    Never should the consequence of a failed or delayed prior authorization transaction be imminent risk of death or serious harm to any patient, but certainly not to a child. How can turning away parents at the pharmacy ever be an appropriate way to structure an authorization transaction? Don't our laws protect children from unnecessary harm? We must classify as medical errors all undue delays or inappropriate denials in the face of clear and convincing evidence that would, upon review by two unbiased experts in the same specialty as the prescribing physician, have supported approval. Such prior authorization errors must be reported, and there must be consequences for reckless, wrongful denials.

    When there is harm to a patient, the consequences must be serious, and I call upon all regulators and legislators to take notice and render aid. Physicians should immediately begin reporting all egregious prior authorization denials as medical errors, and I call upon the American Medical Association and all other organizations that protect patients and defend the provider-patient relationship to endorse medical error reporting in the context of prior authorization. We must focus on protecting the most vulnerable patients first, such as children, indigent patients, and all of those who otherwise can't fight abusive coverage denials without the assistance of the medical profession.
    CONFLICT OF INTEREST: Expert testimony (not involving prior authorization denials)
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    Bless You
    Brian Gamborg, MD | LSU New Orleans
    Harvard Business Review alleges that there are 10 administrators for every physician.

    After completing prior authorizations for prednisone and Bactrim and discussing these with what sounded like a 15 year old in the Philippines I was allowed to provide the medication

    I agree that some stewardship is required, but this is not the answer
    CONFLICT OF INTEREST: None Reported
    The Intended Purpose of "Prior Authorization"
    John Jacobs, MD | Private Practice
    Nowhere in Dr Resneck's article is the intended purpose of "prior authorization" explicitly stated. The purpose is to make money for the insurer, whether public or private.

    Honest use of language is important in medicine. A physician authorizes a medication when he writes a prescription. "Prior authorization" refers to an insurance company not authorizing itself to pay for a medicine, prior to its knowing anything about a case. Insurance companies are referred to as "health care," which is deceptive. The bottom line is that insurance companies often have a
    motive very much opposed to health care, since they lose money if they pay for treatment.

    Most patients have no choice in their health insurance; the employer selects the health insurance. The health insurance pays the physician or clinic, and the patient is out of the loop. When the physician works for the insurer, she does not work for the patient.

    Dr Resneck recommends something akin to "outlier profiling," in which those physicians whose prescribing practices deviate from the mean would be targeted with burdensome paperwork. The result, however, would be to hurt patients, by hurting those physicians who treat each patient as an individual, and to reward those physicians who force each patient into a Procrustean treatment bed. William Osler said, " The good physician treats the disease; the great physician treats the patient who has the disease."*

    Dr Resneck writes that a 2018 survey of practicing physicians reported a mean 15 hours a week spent seeking prior authorization. He notes that 37% of prescriptions initially rejected at the pharmacy are abandoned. He notes that prior authorization for medications to treat diabetes, schizophrenia, depression, and bipolar disorder, are associated with worsening disease status and increased hospitalization. Yet he refers to the call to abolish prior authorization as "unrealistic."

    How many patients have died as the result of "prior authorization?" Would the author of such a study be profiled as an outlier?

    * The Pharos, Autumn 2019, Tobias Venner, a 17th Century Oslerian Prototype.
    CONFLICT OF INTEREST: None Reported
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    Medication Prior Authorization
    Cynthia Jones |
    I agree with the majority of the issues mentioned in the Viewpoint and just want to offer a few observations and comments.

    First, mid-level providers are increasingly caring for medically complex and difficult cases, sometimes with no direct supervision from physicians. The growing complexity of new medications and possibly, the lack of understanding of fundamental principles of pharmacology, and difficult with keeping up to date with new guidelines may have led to an increase in inappropriate use of medication and to stricter scrutinization of requests.

    Second, medication selection is greatly influenced by pharmaceutical reps that visit
    physicians offices. It is not unusual to see a surge of requests for a specific medication for no other obvious reason.

    Third, the decision to approve or deny a request is greatly dependent upon the availability and completeness of medical information provided to the insurance company.
    CONFLICT OF INTEREST: None Reported
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