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Rheumatology Practice Management August 2015 Vol 3 No 4 - Insurance and Benefits, Online Exclusives
Kyle C. Harner, MD
Managing Partner
Carolina Arthritis Center
Greenville, NC

I declare 2015 to be the year of the prior authorization. We are slowly drowning in a sea of paperwork. I am not just talking about paperwork to get a rheumatoid patient approved for a biologic treatment. I am talking about prior authorization forms for methotrexate, prednisone, generic Ambien (zolpidem), generic Skelaxin (metaxalone), and many other commonly used generic medications. At the very least, these forms are annoying, but I feel they also lead to delays in needed patient treatment. You will never see this in an insurance plan policy manual, but these prior authorization forms are a tactic to slow down the delivery of patient care and to frustrate doctors and patients. The insurance companies hope we will decide it is just too much work. In many cases, this is exactly what happens, as clinic staff do not have the time available to continue filling out prior authorization forms for every prescribed medication. Many patients just pay out of pocket for these generic medications, rather than changing to a less effective medication on their formulary.

I guess that I shouldn’t complain too much. After all, the nurse who works with me gets to deal with most of this mountain of paperwork. But I would rather pay this person to help me take care of patients, not a pile of paper. Every piece of prior authorization paperwork that we receive is a barrier to patient care. It is the insurance companies’ way of funneling physicians into whatever path THEY feel is best (for best, insert cheapest). In essence, the insurance companies have become the physician. As doctors, we have to keep asking them if this or that medication is OK. Make no mistake, it has reached the point where THEY are making the treatment choices.

I will stop complaining now, because I actually have a plan to solve this problem. Here it is—let the insurance companies make the treatment decisions. As a physician, I will see the patient and make the diagnosis. PERIOD. Then, the patient will go to the insurance company for a prescription to treat the diagnosis that I make. The patient then will follow up with me to see how he or she is doing and for me to monitor any needed labs. If the patient is not doing well—you guessed it—he or she will go back to the insurance company to have a change made in the treatment regimen. If there are any complaints or side effects, sorry, please call the insurance provider.

Can you imagine these interactions between patients and their insurance companies? It is unlikely that the insurance companies would hire an army of healthcare providers to make these decisions. More than likely, untrained personnel would use cookie-cutter algorithms, or a computer might just spit out the treatment plan. All patients with rheumatoid arthritis would start with triple therapy (methotrexate, sulfasalazine, and hydoxychloroquine) and take years to progress to treatment with biologic agents. Meanwhile, many would become disabled and have erosive disease that could have been prevented with proper, aggressive treatment.

This plan might work really well. Working well to me means that Insurance Company, MD, fails miserably at the above plan. As a result, doctors are again given the responsibility of prescribing what they feel is the best treatment regimen for each individual patient. This is what we were trained to do, and we are good at it. Most of the prior authorization paperwork will go away, and doctors will get back to the business of treating patients.

If the plan doesn’t work well—to me this means that Insurance Company, MD, becomes the new norm in medicine—then physicians and their staff would at least not continue to see piles of prior authorization paperwork. Office visits would be shorter, as we would not be discussing the risks and benefits of therapies (remember, this is Insurance Company, MD’s job now). Medical students would learn SOA notes instead of SOAP notes. A plan would no longer be required from our end. Again, this would be Insurance Company, MD’s responsibility.

Some of this article is tongue in cheek, of course. I do not want to lose the responsibility of trying to make the best treatment decisions for individual patients. What I would like to lose is the paperwork. I still feel that the P portion of the SOAP note is essential to quality patient care. Quality here means prescribing the treatment plan that will keep the patients as functional and symptom free as possible. This kind of quality doesn’t always come at the lowest cost, but in the long run everyone wins—doctors do their job, patients feel better, and insurance companies provide the coverage that their beneficiaries signed up to receive. I am a dreamer, I know.

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Last modified: September 18, 2015
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