The mother recently changed insurance and received notice that her son’s TNFi would not be covered. The physician was not surprised and said the office would obtain prior authorization. Again, the medication was denied. The physician reached out for a peer-to-peer review, and the peer, a radiologist, reported the TNFi would not be authorized because the patient must have failed a conventional disease-modifying anti-rheumatic drug (DMARD) first.
The physician explained this was a continuation of current successful treatment; however, the physician was told the rules are the rules and no exception could be made. The physician escalated the prior authorization review to the medical director, who finally agreed to allow treatment with a TNFi, stating, however, that a different agent must be used because the prescribed treatment is not on formulary for the current insurance.
Dr. Christina Schutt
The physician reported back to the mother who remained worried her son will flare with a change in treatment and couldn’t understand why the physician was unable to convince the insurer to continue the current treatment.
This case illustrates a number of different ethical issues that are all too familiar to practicing physicians, who must balance trying to address the needs of one patient while responding to rules and changes that add time to a schedule already stretched thin.
Prior Authorization Struggles
Nothing is more frustrating or infuriating for a physician than spending time on hold with an insurance company to plead for approval so patients can obtain the medications they need, only to be met with cookie-cutter guidelines, forcing the physician to follow the guidelines or risk spending hours more on the phone. This is exceedingly common in pediatric rheumatology, in which many drugs are used off label, due to the difficulty of performing studies in the pediatric population.
Decisions often appear capricious. Companies may demand the use of a tablet in place of an expensive liquid despite the fact that the patient is a toddler. Companies may insist that all patients with any subtype of JIA be treated with a TNFi first, despite ample evidence that this class of medications does not work for systemic JIA. Patients who have been stable for years on one medication may be asked to switch to a different medication due to a sudden formulary change.
A practice of just three physicians would require one full-time employee to focus solely on prior authorizations.
This antiquated system forces physicians to make decisions about when a fight is worth the effort. Going through multiple appeals may take hours, while changing medications in response to insurance rules may cause patients to question the original treatment decision, interfering with the doctor-patient relationship.
