I’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.

This 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.

We 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?

Photo courtesy of http://www.freedigitalphotos.net

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Key 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!