Letters to the Editor

Amy E. Foxx-Orenstein, FACP.

Readers react to PBMs


Editor's note: ACP InternistWeekly's March 18 edition covered a court's decision to award internist Gary Gibson, FACP, money to cover the cost of filling out information forms from a pharmacy benefits management company, Medco. We asked readers to share their views through letters and an online poll in which nearly 92% of respondents voted that it was “about time someone did something about all the unreimbursed paperwork.”

Following is a sampling of their comments:

The article about Medco highlights an issue that is consuming hours of physicians' time each week. It is also disingenuous for Medco to claim that they are only doing what the insurance companies want. If Medco were not making lots of money, they would not still be doing business. Their interests have very little to do with the patient.

There are several times a week that I have to fill out prior authorizations and/or medicine refills, fax them in and then the patient is told that I never did it. I am left having to repeat the entire process. Apparently, there are several faxes a week lost. Additionally, meds that have been authorized before need to be re-authorized on an annual basis. I could see two to three patients more a day if I were to add up all the time spent on such paperwork. It is not just Medco, there are other companies that have similar systems, but Medco is one of the more cumbersome and time consuming.

Dr. Gibson should be congratulated for finally saying enough is enough!

Geilan Ismail, ACP Member
Taos, N.M.

For years, I have become ever increasingly frustrated, stuck in the catch-22 of the insurance company's exploitation of my ethical obligations of doctor-patient responsibility, holding my patients hostage while demanding significant unreimbursed labor from me. Dr. Gibson is to be commended for his legal insight at bringing this case. I would now ask the ACP for guidance in developing this into a viable precedent nationally.

Mark D. Hauptman, ACP Member
Mission Viejo, Calif.

I find Medco prior authorization forms to be not only time consuming and not reimbursable, but frankly a form of practicing medicine on their part. I have had prior auth forms questioning the use of testosterone replacement therapy asking for the diagnosis as primary or secondary, whether the correct labs were run to differentiate the two, and the test results. I have had forms regarding the use of alpha blockers for BPH and ED meds with questions that I think reach medical decision making levels on their part.

I believe these forms are specifically meant to be time consuming so that doctors simply don't complete them and they (PBMs) save money consequently. In relation to this issue specifically I spent more than 45 minutes one day amongst supervisors without satisfaction. I asked if they had a physician that I could speak with and I was told by this second-level supervisor there were no physicians in Medco.

Substituting one ARB for another is one thing, but Medco's tactics should be illegal if they are not, and if they are illegal then they should be forced to stop. I love my job within the exam room's four walls, but sign me up for anything to simplify and minimize prior authorizations.

Jeff Atkinson, ACP Member
Pasadena, Md.

How refreshing to see that Dr. Gibson has successfully sued Medco for payment for prior authorizations. Perhaps other actions against other companies will follow.

It is surprising how many physicians and their employees spend countless hours responding to the administrative requests of insurance companies. Does anyone think an attorney would perform such services without billing by the minute? Until physicians require payment for their administrative efforts, their overhead will rise in parallel with the profits of the insurance companies.

I have long ago taken the position that my prescription is my prior authorization and should not be challenged by someone without a license to practice medicine. Presumably a patient consults a physician to receive the best advice and treatment available. If the quality service is denied the patient by the insurance, then it is up to them to resolve the dispute. This should not affect the medical decision regarding quality care, assuming that the decision has been made thoughtfully and without commercial bias.

James O. Wells, FACP

As an Ohio physician, I was pleased to note the recent favorable ruling that Medco prescription authorizations were primarily to save money for Medco and the subscribing plans.

We are truly caught in the middle, filling out two-page detailed forms asking such trivia as “which prior PPIs were tried and for how long and when” before Medco might consider—or more commonly reject—authorizing a particular drug, as it did Friday after I filled out a detailed request. For a while, we simply faxed the request back with a form letter, suggesting that the patient come in for a face-to-face (i.e., reimbursed) visit to discuss the request. Yet we are also seeing patients with increasing co-pays and even no coverage for office visits, who are unwilling to come in. The recent article in Geriatrics detailing the geriatric clinic survey of work performed on behalf of patients between visits that equaled eight hours weekly—an entire work day performing non-reimbursable requests—is sobering, and should come as no surprise to those in primary care who are coming in earlier and staying later, or taking paperwork home. Clearly the lawyers are ahead of us in this issue, billing for work by the minute performed outside of office visits.

As yet, there is no solution to the dilemma, but it is one of the major factors in the declining satisfaction with primary care.

Georgia L. Newman, FACP
Oberlin, Ohio

Life after prostatectomy

I was extremely disappointed in the review of the quality of life effects of treatments for prostatectomy ACP InternistWeekly, March 25. The reviewer completely missed the main point of the article, which is that patients undergoing prostatectomy have much worse sexual function outcomes, even with nerve sparing procedures, and that the quality of life of the spouse is affected most negatively by prostatectomy.

The authors of the article were tip-toeing around their conclusions as well, undoubtedly to avoid offending urologists. But the data speak for themselves. Clearly, side effects and quality of life outcomes vary by treatment. The lesson of the article is that we need to make the patients aware of the likely outcomes so that they can make choices based on their own priorities.

Michael J. Kraut, ACP Member
Southfield, Mich.

Advocate for primary care

The College has done all general internists a great service by promoting the patient-centered medical home. If fully adopted, this reform could transform primary care medicine in the U.S. But now is the time for the College to advocate for measures to stem the tide eroding our primary care base.

Here are eight things that CMS could do tomorrow that would strengthen the patient-centered medical home.

1. Reimburse physicians for warfarin management by telephone. The CPT editorial advisory committee recently adopted codes describing the service. In my region commercial health plans are uniformly paying for this service. The payback to Medicare is immediate. Warfarin is a dangerous drug and careful management results in fewer hospitalizations and emergency room visits. Payment could be dependent upon meeting structure or process measures in regard to safety.

2. Reimburse physicians for care plan oversight at assisted living facilities. Assisted Living Service Agencies provide services similar to home care agencies. Physicians are currently reimbursed for care plan oversight and institution of services at home care agencies, why not at assisted living facilities?

3. Reimburse physicians for the time and effort required to obtain, store and transmit advance directives.

4. Reimburse physicians for telephonic family conferences during sudden changes in patient status. When the patient is hospitalized or admitted to a nursing home, out-of-town family members require information from the primary physician.

5. Reimburse physicians for drug plan management. Medication reconciliation is crucial during the many “handoffs” in our health care system. This is unreimbursed service yet critical to avoiding hospitalization and clinical deterioration.

6. Mandate that Medicare Advantage plans reimburse physicians for prior authorizations. The benefit for this service accrues directly to the health plans and physicians are not compensated for the time and effort spent in assisting patients.

7. Mandate that Medicare Part D plans reimburse physicians for the time and effort spent in changing new enrollees medications to match plan formularies.

8. Reimburse physicians for continuity of care records transfers. When the patient is admitted to a hospital or a nursing home, physicians are frequently asked for a summary of the patient's problem list, medication list, immunization records and advance directives. These record transfers reduce the costs and improve the safety of care yet require significant time and effort.

I urge the College to advocate on behalf of these measures.

Rodney Hornbake, FACP
Hadlyme, Conn.