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Palm Beach Post: Patients, doctors should get final say on drug choices

Navigating the health care system is complicated enough for most Floridians. Adding to the hoops to jump through, patients must battle with insurance companies and pharmacy benefit managers (PBMs) for coverage of the treatments and medications their doctors have prescribed. Certain cost-cutting practices used by insurance companies and PBMs put profits first — forcing doctors and patients to pay the price.

Over the past several decades, insurance companies have developed policies that allow them to review and alter certain doctor-prescribed treatments and medications before agreeing to provide coverage. One policy, known as prior authorization, allows the insurer to refuse payment for a prescription until the doctor has provided lengthy documentation to justify that it is medically necessary. Another, called step therapy, allows an insurance company to request that a patient try out a cheaper alternative medication before receiving the one that was originally prescribed.

While prior authorization and step therapy are reasonable in many cases, for some patients they can result in dangerous delays. Under certain step therapy protocols, doctors and patients are forced to undergo a lengthy appeal process — even after the cheaper alternative recommended by the insurer has already failed. Even if the circumstances are not life threatening, waiting for an insurance company to review an authorization can substantially reduce the quality of care. In some critical cases, treatment can be delayed for months.

Prior authorization and step therapy have also created an unnecessary burden for doctors, who must spend valuable time compiling records and test results and ensuring that all the necessary documentation gets to the correct department at the patient’s health plan. This process takes up a considerable amount of time that doctors could be using to provide quality care to patients. The American College of Physicians (ACP) estimates that the average doctor now spends two hours on administrative tasks—including insurance and billing-related issues—for every hour spent interacting with patients. Taken together, physicians now spend 49.2 percent of their time on average completing paperwork and only 33.1 percent interacting directly with patients or staff, according to ACP estimates.

Whatever insurers save from prior authorization and step therapy comes at the expense of physicians and their patients. Private practitioners pay a particularly high price. The American College of Physicians (ACP) estimates that total costs amount to anywhere from $68,000 to $85,000 a year per doctor, or 14 percent of revenue, nearly one-third the income-plus-benefits of the average primary care physician. Additionally, cost savings are seldom passed on to the consumer. In many cases, patients end up paying a disproportionate share of the negotiated net cost for their prescriptions.

The ultimate decision about patient treatment should not be made by the insurance industry and PBMs.

Doctors take an oath to do no harm. That is why patients trust that their doctors will always put patient care before financial considerations. The insurance industry and PBMs do not agree.

Restricting the ability of insurance companies to delay or deny essential treatments would put patients before profits.


Editor’s note: Dr. Robert Levin is president of the Florida Society of Rheumatology.

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