1 comments
These are my thoughts and comments on the draft Pharmacy Provider Manual under Covered Services and Limitations. I believe issues bordering on prescription drugs are essential to patients’ recovery plan; and so, I feel the Medicaid prescription drugs prior authorization under the Code of Virginia law may be having an impact on Patients’ total health care and therefore requires attention and must be addressed in the draft.
The Medicaid Prior Authorization Advisory Committee, which is under the Department of Medical Assistance Services in Virginia, oversees the prior authorization policy on the use of prescription drugs in the state. Besides this oversight role, the Advisory Committee is further tasked to consider the potential impact on patient care and the potential fiscal impact of Prior Authorization policy on pharmacy, prescriber, hospitalization, and outpatient costs. They are to accompany such a proposal with a statement of the estimated impact of making a drug or class of drugs subject to prior authorization.1
The legislation
The regulation governing the subject mentioned above is Article 4, subsection 32.1-331.15 of the Code of Virginia law states that "coverage under the state plan for any drug requiring prior authorization shall not be approved unless the prescriber obtains prior approval of such use in accordance with regulations promulgated by the Board and procedures established by the Department”.1
Prior Authorization
Prior authorization (PA) refers to the practice where some treatments and medications may need approval from the health insurance carrier before the patient receives care under medical and prescription drug plans. Prior authorization is usually required if you need a complex treatment or prescription.
The types of prescription drugs that typically need approval include the following: those that are considered unsafe with other drugs, drugs with generic substitutes which an equally effective and cost-effective, drugs which are to be dispensed for only some specific kind of medical conditions and are prone to abuse/misuse, and those used mainly for cosmetic reasons.2 Thus, when any of the categories mentioned above of drugs is needed for a patient, the doctor must send a request to the insurance provider, justifying the need and must receive approval before use.3
Impact On patient's care
The first impact on the patient is delayed recovery – a patient looking for treatment for their pain and ailment as early as possible is compelled to endure unnecessary pain for much more extended periods. The patient's schedule, comfort, and convenience are all distorted. There is also the issue of work time loss if the patient had to wait extra days to commence treatment and, therefore, recovery time. Sometimes it stretches from days to weeks as patients must wait to be called for approval. In some instances, the drug may not be approved after the initial application by the doctor, and a second or appeal is submitted before it is finally approved. Suppose the patient happens to be vulnerable such as a child or elderly who needs a time-dependent treatment, medical service, or prescription drug. In that case, the situation can be life-threatening. The more time-consuming these processes are, the further the delay in therapy, causing disease severity. Increased healthcare costs are an indirect impact of delayed treatment.
Evidence
Available empirical evidence supports the assertion that prior authorization is usually not in the interest of the patient. A study conducted by Jew (2020) on the effect of prior authorizations in patients with complex dermatologic conditions posit that in dermatology, prior authorizations can delay treatment, decrease patient adherence, and deter providers from advocating for their patients.4 They added that patients with complex dermatologic conditions, often requiring off-label treatments, may face particularly significant insurance barriers. The results of their study show that of 51 prior authorizations, 51% were initially denied, with systemic medications more likely denied than topical ones (P < .001). Total administrative time spent on 50 prior authorizations tracked was 62.5 hours (median time per prior authorization 30 minutes [interquartile range 17-105 minutes]). Time to access treatment was tracked for 80% of prior authorizations; the median delay was 12 days [interquartile range 5.5-23 days]. They concluded that Patients with complex dermatologic conditions face a significant barrier to care because of prior authorizations. The administrative burden for provider practices to address these prior authorizations is substantial and may warrant a streamlined system in collaboration with insurers.4
A study by Popatia (2019) to examine the effect of a centralized pharmacy intervention on the prior authorizations process and the impact of PAs on patient outcomes concluded that the current PA process may result in delays in care and a negative impact on patients.5 A centralized pharmacy intervention is an effective measure but does not eliminate the overall burden of PAs. Their methodology was simply a retrospective review of PAs submitted for medications before and after implementation of pharmacy intervention was conducted.
They arrived at said conclusion based on the results of their study, which showed that PA was required for 8.1% of all prescriptions. PAs were most frequently submitted for topical steroids, topical antibiotics and antifungals, and topical retinoids. The most common indications included acne, psoriasis, and dermatitis. Biologic agents (55.2%) and brand-name-only medications (42.8%) required PA at higher rates. Pharmacy intervention resulted in shorter time to PA submission (4 days vs 1 day, P < .001) and decision (6 days vs 1 day, P < .001) and higher approval rates (63.9% vs 80.6%, P < .001) but did not decrease the total number of PAs. Patients with approved PAs had a higher likelihood of disease improvement vs. those with denied PAs (71.1% vs. 58.0%, P = .013).
Opinion
There is a general perception that the policy on Prior Authorization merely protects the financial interest of the insurance companies rather than the patient. It is as such my submission that the commissioning of the Advisory Committee to review the potential impact of the regulation on patient care is laudable since indeed there have been various challenges impeding the smooth working of doctors and on patient care generally, resulting in numerous delays and frustrations to prompt medical intervention. This position is supported by the multiplicity of public comments in that regard.
It is also my considered opinion that prior authorization of prescription drugs leads to delayed treatment of patients and the situation impacts negatively on both patient and industry as in many instances, it results in disease severity, reduced quality inpatient care as a whole, and increased costs for both providers and insurance companies.
Many providers think the hustling by insurance companies is to get providers to dispense cheaper generics since brand drugs are expensive. In my view, there should be a collaboration between doctors and insurance companies to design modalities that will lead to a consensus.
I am also of the view that prior authorization for prescription drugs undermines the competencies of doctors and their ability to give optimum care for their patients. The situation can demoralize caregivers and affect their work output and efficiency. Loria (2019) reported that many doctors view it as an interference of the care decision-making process, thereby creating problems and hardships for both physicians and patients.6
Finally, the social impact support and care from family and loved ones are equally stretched and become burdensome. When a family member is affected, the entire household is impacted as well. The frustration created by prior authorization to families can be taxing and form an avoidable barrier to patient care.
Conclusion
Despite the good intention of providing protection and ensuring that patients receive safe, medically necessary, and appropriate treatment, including prescription drugs, necessitating prior approval of prescription drugs may instead be undermining the competencies of doctors and creating unnecessary burden and hardship to patients. Patients need timely treatment, social support, minimal work-time loss, customer care, and proper satisfaction towards their total wellbeing. As such, extra burdens and barriers during their therapy necessitated by the prior authorization regime create delays, the time-consuming processes impede these goals.
Recommendation
It is recommended that drug formulary and inclusion criteria of drugs that require prior authorization must be done in consultation with caregivers in their various fields of specialty. Additionally, the current list of drugs that require approval must be frequently reviewed and updated appropriately by all stakeholders to lessen the patient's burden and speed up treatment and requirements on prescription drugs that hitherto required prior authorization.
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