Dirty Secrets of Health Care, Part II: Preauthorization
The many ingenious ways to say no and hinder care.
Posted November 8, 2015
We Know How to Say No
Nancy Reagen was right. You just say no.
Except health care companies have learned new, exciting ways to say no – for their bottom line. And how they do it will receive understanding winks from bureaucrats around the world – give the appearance of due process, of fair hearing, of concern.
Just don’t make it real.
And along the way provide a strong teaching lesson – that their bottom line truly is the bottom line. Physicians have to know who the real boss is when it comes to health care.
It’s not them – nor the people they care for.
Preauthorization is a term that strikes a Pavlovian response in doctors, nurses, and health care people throughout the U.S. When I ask colleagues about preauthorization, they said “don’t waste your time – they just say no.”
Actually it’s a lot more complicated.
Some years ago I documented one of my forays into the pre-authorization game - then for prescription pharmaceuticals. A rather small group of pharmacy benefit companies now control the industry. The word for it is oligopoly – a few companies set the word. There are supposedly anti-trust statues around for over a century to deny that type of control – but lawyers, lobbyists and campaign contributions can nullify that. How else can Medicare – alone in the world – not legally be allowed to bargain with drug companies?
In one instance, I was asked to talk with a pharmacy benefit company about giving a patient a generic drug. It was not the cheapest possible generic antidepressant – instead of pennies per pill this one was about ten to twenty cents. Over time, that’s money. But the patient had done far better with this medication with others, so I thought I would try my bit.
Of the seven “representatives” I was asked to speak with, only four demanded my patient’s social security number, address, history - most of which they were looking at on their screens. A few demanded my full bona fides. Eventually I was allowed to speak to a corporate pharmacist. He agreed to accept the medication at the dose used.
After an hour, here was success. Until I saw that the dose “agreed to” was half what she was taking. I fought again, but the end solution was to buy the stuff at Walmart.
Recently, however, the game has morphed. Faxes from pharmacy “representatives” are sent as a bright white blizzard every morning.
They have already been sent through the prescribed electronic prescribers. They are often done at the demanded “three months, three refills” formats the pharmacy benefit company demands. They have electronically gone through. The medications are often among the cheapest known.
Except they all have to done all over again. Usually they require that the same information on top of the fax must be handwritten below it again - by myself or my "representative." After this makework, I can finally append my explanation as to why the patient should take the drug.
After all, how dare I give out an antidepressant like fluoxetine (prozac)? What possible explanation could I give for such effrontery – especially to someone who had done well on it – and terribly off.
Recently a new curlicue appeared. A patient I see yearly – who has done well with antidepressants, so well she really doesn’t want to see me for much else, found that the constantly changing generics provided by her insurer “did not work.” The “new ones” also made her ill.
She wanted to take the brand. She trusted it. She would pay for it out of pocket. I duly wrote out a prescription with the explanation of why the brand was preferred.
The next day I get a fax. I'm not allowed to explain anything. It was only given a phone number to call.
So I instructed my staff to call and ask for a preauthorization form. I would fill it out and explain what happened to her. Perhaps they would find a way to get the old generic – though she said she was not so interested.
After speaking with four separate individuals, the secretary was told a fax would be sent.
It was. It was the same statement from before, requiring us to call. Then, later on, another fax appeared. It stated “the next fax will be the preauthorization fax.”
Except there was no further fax. Zip.
Coincidence? A failed fax machine?
Except it kept on happening, to different patients. A fax would appear stating we needed to call to get a fax. Following the call, a fax would appear, stating the next fax would contain the required form.
Except it never appeared.
The Real Lesson
American medical care is a balls-up mess. But the ways in which it is now being perverted are both exquisite and intense.
Just as with the ad agencies, whose pharmaceutical television adverts list side effects that include death and dismemberment but tell you to “ask your doctor,” the game of liability and control is clear.
If you want preauthorization – even for things that cost pennies – we will waste your time. We will tie down both you and your staff so you can’t see patients. We will send you on goose chases and down cul-de-sacs you cannot escape. And when you tell patients that we are intractable, we will simply declare it’s your fault for “not sending in the form.”
We’ve done our bit. Due process is complete. The lawyers say we’re clear.
And one message to physicians is clear – do as we say. Period.
But there is another message. It is that waste and frustration and anger are now routine adjuncts of virtually any medical transaction. With basic elements of treatment denied, doctors and patients can spend millions of hours on the phone, pointing fingers, shouting, complaining about the “system” as the people with greatest control of that system walk off to the bank.
Do doctors do too many procedures and expensive tests? Sure. But preauthorization could work. It could be done in protocolized fashions that let people know the real costs of treatment or non-treatment. It could be also be reviewed by panels – as in civilized countries – which weigh cost and benefit.
But we are way beyond that point in America. Our health care system does not provide health. Too often it is programmed to provide grief.
And some find that very profitable indeed.