“That requires prior authorization” is not
what we want to hear if we are a patient or a physician. However, requirements
for prior approval for certain procedures and medications are here to stay in
the health care industry. Problems arise as health care providers’ drive to
treat their patients using the finest that medical technology provides clashes
with the insurance company, who as a business, desires to control costs as much
as possible. The insurance industry pays the vast majority of health care costs
in this country and, since they are a business, they wish to make a profit, and
controlling costs is a necessary component. Sometimes the requirement to
control expenses as well as the need to treat patients can be reconciled. Frequently,
however, both of these requirements cause a struggle.
One
common area of conflict is in the use of antirejection medications for
transplant patients. Transplant medications must be taken by transplant
patients for the rest in their lives. This is often very expensive which is why
insurance providers usually only cover the generic form of the drug, not the brand
name. While generics generally work fine for some more common conditions like
blood pressure, many physicians don't trust the generic type of antirejection
drugs, frequently for good reason. However, because the expenses are being paid
by the insurance companies, patients are typically left acquiring the generic
medications against their doctors’ advice.
CBS News “60
Minutes” recently described the clash between insurance companies and
physicians regarding mental illness. Cases of insurance providers, who never see
the individual, are declining to cover the full course of treatment which has
triggered needless suffering and in some cases, death.
Medical
economists explain that the cost of complying with all the prior authorization requirements
is time consuming and very costly. However, without a public policy solution
for the issue, there are certainly a few things the physician may do to
streamline the process.
First, if
an insurance business is slow to pay or is too rigid in granting approvals, the
doctor may consider not seeing patients with that insurance. If enough
healthcare providers do this, insurance companies will begin to get the message
and may modify their techniques.
Second, doctors
must try to structure their prior approval processes in the most efficient way.
Strategies include: use the insurance company’s website instead of calling on
the telephone; try to get blanket approvals for common procedures and common
medicines; centralize the approval operations; and lastly, doctors should learn
which drugs and procedures do not require prior authorization and use those if
they are appropriate.
Although these recommendations won’t
resolve the situation of working with insurance providers, they may make the
process a little easier.
