How “prior authorizations” impact kids with disabilities…

ID-10082836I’m going to take the opportunity to vent today about an element of our modern healthcare system that is poorly understood by most families and the single intrusion into our child psychiatry practice most likely to overwhelm my anger management skills…”prior authorizations.”

When a parent leaves our office and drops a new prescription off at their pharmacy, they’re often informed they won’t be able to get their medication until someone from our office calls a clerk associated with their health plan or pharmacy benefit manager subcontracted by their health plan to authorize payment for the prescription.

It has become increasingly common for families to have coverage switched from one insurance company to another from year to year. Insurance companies will periodically cut deals with new pharmacy benefit managers that work from different algorithms of “preferred” drugs. We’ve historically had a limited number of families obtain secondary health insurance through Medicaid that paid for much of the cost of necessary prescriptions. Each of these events usually triggers a “prior authorization” request…in these cases, the insurance company or pharmacy benefit manager is generally refusing to pay for medication that has been demonstrably effective for that child.

All of this is presumably done in an effort to contain the cost of health care…but it may only be successful in containing the costs for the entity overseeing the pharmacy benefit.

shutterstock_174158831This process is a nightmare for families…especially families of kids impacted by significant disability. Insurance is very expensive. Families have larger and larger “deductibles” before insurance benefits kick in, and an increasing number of companies refuse to count the cost of medications families pay for out of pocket toward the deductible unless the medication is first “approved”…even though the insurance company isn’t actually paying for the medication. Families of limited income may have no recourse if insurers refuse to pay for medication or other necessary treatments.

We had a member of our office staff quit (to a large degree) because of her frustration with the process she needed to go through to get prescriptions authorized…and the verbal abuse from anxious family members who assumed we weren’t doing what we needed to for their kids to get their medication. I’ll paraphrase the end of the phone call that put her over the edge-after waiting on hold for an hour to speak to a clerk who refused to authorize the prescription written by our physician…

FCBTF staff: Can we have our doctor speak to your doctor who oversees these decisions?

Insurance clerk: We don’t have a doctor.

FCBTF staff: What are your qualifications?

Insurance clerk: I’m a college student.

I’ll share two particularly egregious anecdotes from personal experience this past year…

I was treating a very complicated kid with ADHD, separation anxiety, obsessive thinking and  inflammatory bowel disease who had major difficulties with academic performance, behavior and school attendance despite working with a very qualified counselor.  We found that the combination of a low dose of stimulant medication and atomoxetine (a non-stimulant medication approved for treatment of ADHD that has also been demonstrated to be helpful for several types of anxiety in kids) together with ongoing counseling was very effective in helping this kid to attend school and succeed in school for over a year.

One day, the parent calls us in a panic because their new insurance company refuses to pay for the atomoxetine. After our office staff literally spends hours on the phone with this company and I spend a half-hour (uncompensated, of course) writing a report describing the kid’s treatment and response to every medication they’d received, the company determined we would need to stop the current medication and rechallenge the child on their “preferred” medication even though the company’s “preferred” medication produced a serious adverse reaction fifteen months before. How could any physician in good conscience (or any parent) stop an effective treatment and subject a kid to medication that produced a significant negative reaction as a precondition for accessing healthcare benefits to which they were entitled?

More egregious was the case of a very complicated teen with a severe mood disorder who had been stable for over a year on a combination of medications that included aripiprazole. The parent goes to their pharmacy to pick up a refill and is informed that the medication is no longer covered. Despite the efforts of our staff to get the medication approved, the company insists on only approving an alternate medication. By day five, the police were searching for this teen who was missing from home. When the police found the teen, they required admission to the psychiatric unit of a local pediatric hospital. For three days, the staff of the local pediatric hospital fought with the insurance company that maintained their refusal to pay for the medication. The pharmacy benefit manager only relented when the hospital refused to discharge the patient until they had been stabilized on the prior medication.

The pharmacy benefit managers and insurance companies are shielded from liability in most states for their denials of coverage…they say they’re not practicing medicine but simply making determinations about the benefits covered.

I have a peer who works in a clinic serving indigent kids in another county in Northeast Ohio. She tells me she commonly has to see kids and families with a phone held to her ear while she waits on hold to speak with clerks at the Medicaid HMOs so that the patients she saw earlier in the day are able to get their prescriptions. Another colleague serves as Medical Director for Children’s Services at our county’s primary mental health center. Last year, they had two full-time employees on staff (supported by public funding) to deal with the necessary bureaucracy so that the patients served by the agency’s three full-time doctors could fill their prescriptions.

There were times early this year when our staff was spending so much time on hold with phone calls for prescription authorizations that patients couldn’t routinely get through to our office to schedule appointments. One company wants to delegate the responsibility for submitting prescriptions to our office staff. We had another company suddenly demand that someone from our office call to give a comprehensive history every time a patient goes to the drug store to fill a prescription. Upon completion of this review, our staff would then be given an authorization code that they would be required to call into the patient’s pharmacy before the prescription could be filled.

Care Cloud ScheduleWe find ourselves needing to hire more staff to manage the process. Every time we have to increase our rates, we know more families will be priced out of their ability to access treatment through our practice. When our doctors have to take time away from kids and families to address insurance company mandated clerical tasks, less time is available for new appointments and kids and parents wait longer for care. When a kid on a stable regimen struggles after being denied access to medicine by an insurer or a pharmacy benefit manager, parents may have to pay for additional appointments to straighten out the mess or take time off for work and children may have to miss school. Most importantly, kids suffer.

Ponder the experience from the parent’s perspective. Imagine the fear when your child depends on a medication or treatment prescribed by a trusted physician. What do you do when a necessary treatment is unaffordable and an insurance company or their designated pharmacy benefit manager arbitrarily denies access to that treatment?

Dr. Danielle Orfi is a professor of medicine at NYU and authored this op-ed piece last week in the New York Times on the frustration this process causes for physicians and their staffs. From her article…

I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.

I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

Feel free to share your story in the comments section below! Have you, or someone you know been adversely affected by nonsensical prior authorization requirements?

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KM Logo UpdatedKey Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!

About Dr. G

Dr. Stephen Grcevich serves as President and Founder of Key Ministry, a non-profit organization providing free training, consultation, resources and support to help churches serve families of children with disabilities. Dr. Grcevich is a graduate of Northeastern Ohio Medical University (NEOMED), trained in General Psychiatry at the Cleveland Clinic Foundation and in Child and Adolescent Psychiatry at University Hospitals of Cleveland/Case Western Reserve University. He is a faculty member in Child and Adolescent Psychiatry at two medical schools, leads a group practice in suburban Cleveland (Family Center by the Falls), and continues to be involved in research evaluating the safety and effectiveness of medications prescribed to children for ADHD, anxiety and depression. He is a past recipient of the Exemplary Psychiatrist Award from the National Alliance on Mental Illness (NAMI). Dr. Grcevich was recently recognized by Sharecare as one of the top ten online influencers in children’s mental health. His blog for Key Ministry, was ranked fourth among the top 100 children's ministry blogs in 2015 by Ministry to Children.
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2 Responses to How “prior authorizations” impact kids with disabilities…

  1. Through all of the disarray so called health care, insurance, lack of insurance, dealing with insurance, it doesn’t seem to matter what experience or what side of the phone one is holding on to. This is a discussion that goes beyond mere ‘prior authorization’ that impacts not only children or the disabled populations. With diagnostic codes, treatment codes, insurance codes the ever changing merry go round keeps on spinning. Be it the physicians, the nurses, office staff, patients, parents or otherwise….the pharmaceutical industry has taken the scope of “treating” people to an “unhealthy level” of money based distribution. On one hand, medication helps, on the other, it has fast become a cesspool of legally drugging citizens for financial gains as opposed to the truest intent of overall quality of care and well being. Starting with children all the way up to the aged.

    To put this in perspective is the astounding statistic that 7 out of 10 individuals are on some kind of prescription drug, notwithstanding those who are on multiple medications.Children are being given medications like candy…for the sake of ‘research’. So are the elderly, the under privileged, and many who cannot afford medication. Parents and patients go to physicians to get better, they trust what they are told and or given. When those medications are uncovered what is anyone to do? Options are to get another medication that perhaps does not work with the same efficacy, or safely be weaned off of one drug to introduce yet another. Or not. For the families with children on medicine that suddenly becomes uncovered, what is then imposed upon and further harmed is the family as a whole.

    What does this say about those within the ‘medicaid/medicare’ systems? If you have coverage, you must continuously submit to the systems of which you are entrenched. Minimizing the importance of “maintaining overall health’ through prevention, and instead promoting un-wellness. The more medication you need, the more money the industries are making. Who needs mouse studies to prove the effectiveness or lack thereof, when indeed every patient or individual knows their body or how medications effect it? Certainly parents know their children best just as much as being able to see without any doubt how any medication is or is not working for their child.

    It is time for us as people to take hold of our health, its time for evidence based treatments that enhance well being, without the first line prescription writing on the prescription pad that keeps patients coming back for more. More importantly is to be able to recognize that God is the ultimate physician and His healing process goes on without taking a pill.


  2. Shannon says:

    This is what happens when government regulates health care, period. And why insurance or universal coverage isn’t a Godsend but instead a nightmare because there is no direct line to physicians, medical care and/or pharmaceuticals. The therapy I had to pay for out of pocket last year was cheaper for me and my son because we DIDN’T involve any insurance companies, despite having excellent insurance. The paperwork alone was a nightmare. It’s only going to get worse, imo.


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