The Uncaring Nature of Managed Care
The Uncaring Nature of Managed Care
Speaking out against the unfair regulations for Prior Authorizations that force patients and healthcare providers alike to jump through hoops in order to follow through on a care plan.
I recently closed out a particularly long work week by spending over an hour responding to and negotiating prior authorization (PA) requirements from insurance plans. I am no stranger to spending an exorbitant amount of time working on this facet of prescribing medication as it is a large part of my work and has been consistently mismanaged and made to be difficult for as long as I have been in this field.
A PA, or prior authorization, by definition is “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan” according to Healthcare.gov. For medications, specifically controlled substances, healthcare providers are made to essentially prove why they have decided to prescribe a particular medication to their patients. This process then puts the decision of whether or not a patient will receive such medication in the hands of their Insurance Company. Realistically, the Insurance Company is deciding whether or not they are willing to pay for the medication or service, but with the state and nature of the Healthcare system in America… a PA denial more or less stops the patient from being able to receive what their doctor has prescribed. Prescribers are sitting with patients, gathering histories, performing evaluations, and generating diagnoses and wellness plans. Managed care companies dictate care based solely on profitability without ever meeting patients. In sum, an Insurance Company employee who has never directly spoken to the patient has more of a say over the medication you are allowed to receive than the medical provider who you have spoken to face to face, has assessed the situation, considered diagnoses, and prescribed said medication.
“Prescribers are sitting with patients, gathering histories, performing evaluations, and generating diagnoses and wellness plans. Managed care companies dictate care based solely on profitability without ever meeting patients.”
PAs are the underbelly of managed care. In theory, PAs stand between overspending of premium dollars by requiring that prescribers provide a rationale for medical decision making. This requirement is conspicuously absent when prescribing generic medications which usually cost less. The PA requirements lead to disruption of treatments that are effective and in some cases life-saving. When a patient switches managed care plans (sometimes under the same insurance banner), a collective amnesia often ensues. Managed care plans cannot understand the rationale for continuation of FDA approved treatments. The adage "If it ain't broke, don't fix it" is tossed in pursuit of maximizing profit no matter the consequences to the patient.
Insurers have given false intel to policyholders, telling them that their doctor can obtain a PA with a phone call to their insurer. FALSE. PAs require a number or hoops to jump through including completion of online forms, mining of office notes for required information, and inclusion with PA request. In most cases, prescribers are not paid for the time needed to process PA requests, which tends to be extensive. This forces some prescribers to charge a fee to the patient for their time. Others will need to hire externally just to ensure that PA work is completed (and often recompleted). Managed care plans will often ask for a second relay of information for a PA request, citing the initial PA request as “incomplete”. On the many occasions when this has occurred in my office, the initial PA was properly completed.
Though the annoyances are many on my end as a provider, the patients are the ones being forced to suffer due to these requirements. Another tactic employed by managed care is the requirement that a patient try 1 or more of their preferred (read "less expensive/more profitable") medications before it will pay for the medication deemed clinically appropriate by the prescriber. I was once told by an insurance company representative that I was free to prescribe any medication I chose "but we won't pay for it." Many times, the insurance company will not specify the number of preferred medications required. A guessing game ensues, the clock keeps ticking and patients continue to suffer through multiple trips to the pharmacy and wasted co-pays as they wait to get well. Managed care companies take no responsibility for delays in treatment. They are not held accountable when one of their preferred medications leads to side effects and/or is ineffective, resulting in continued suffering by patients.
So why are we talking about this now? And what can we do to promote change? We have put in hours upon hours of work to create carefully curated care plans for our patients just to have them thrown out the window by managed care companies. They are getting between us and the patient because of nothing more than money and we are sick of it. While we would like to encourage policy holders to approach their insurers about this policy, this should not be the job of the patients. The change starts with policy reform. Writing to local state representatives or senators is a good place to start. These regulations are in place because a legislator told them it was a good idea to let Insurance companies make a decision over a doctor.
At PsychPhilly, our team recognizes just how hard it is to even take the first step to consider seeking help, let alone beginning medication to further you on your wellness journey. The regulations in place that are making these choices even more difficult need to change for the sake of our patients and the overall wellness of our community.
