Letters to the Editor

Managing depression

As a psychiatrist, I appreciated seeing the front-page article “Managing depression is worth the effort” in the May 2016 ACP Internist. However, I was puzzled by the recommendation that “Patients with severe depression... should be promptly referred to a specialist or psychiatrist.” As psychiatrists are the physicians specializing in mental illness (including depression), what other specialists were intended? I don't believe you could have meant nonphysician specialists (e.g., psychologists), as other disciplines cannot deal with somatic treatments for depression (e.g., antidepressants, electroconvulsive therapy, or repetitive transcranial magnetic stimulation) or take into account potential medical comorbidity.

David A. Gorelick, MD, PhD
Baltimore

Editor's response: The article's author, Kathy Holliman, clarifies that according to the experts she interviewed, internal medicine physicians should be referring complex cases of severe depression with possible comorbidities to a psychiatrist for evaluation, treatment, and management. In addition, her sources noted that some patients with severe depression might also benefit from referral to a psychotherapist who is qualified to deliver evidence-based psychotherapy.

Prior authorization

I don't doubt that practice management columnist Margo Williams had good intentions presenting her recommendations to manage the ever-increasing burden of prior authorization (“Dealing with the hassles of prior authorization,” ACP Internist, May 2016). Unfortunately, I don't believe she fully realizes the depth of frustration and visceral aggravation (certainly for me) that primary care internists face every day.

The telling clause in Ms. Williams' response is “Until such time as the medical world can effect reductions in the use of prior authorizations ....” Let's face it, that time was over 10 years ago! Ms. Williams' tips are, as acknowledged, only mitigation measures and represent abject concession to maintaining the prior authorization process, even as she claims studies have shown that prior authorization is a measurable cost to clinicians. If anything, the scope of prior authorization is continuing to expand to infect even more procedures and medications. Advocating for and providing good care to patients require much more precious time, effort, and hassle. Ms. Williams suggests “dealing” with the hassles of prior authorization, rather than outlining a strategy to modify, reduce the burden of, or hopefully, maybe, end the current process.

Prior authorization management is another sad example of our internal medicine/primary care leadership failing to aggressively and in timely fashion respond in a protective manner to another burdensome imposition on daily practice that negatively affects our ability to provide the best care to our patients. This failure echoes organized medicine's response to the fiasco of the electronic medical record, which is helping to kill physicians' career satisfaction.

Why has there not been any exertion of significant leverage to confront the prior authorization process, quite unlike the strong, rapid response to Maintenance of Certification (MOC)? Do the state medical societies even care? There has been a little talk, but no action. Is it a lack of fortitude? This is doubtful, given the response to MOC. Collusion with the payers? Can't be ruled out. Agreement with the prior authorization process and a “blame the physicians” mentality? If so, say so, but I certainly hope not!

My recommendation: Tips for mitigation may help a little; taking a strong stand may help a lot.

Michael E. Miller, MD, ACP Member
Boston

Ms. Williams responds: Dr. Miller is correct that it was my intent to help practices mitigate the hassles of prior authorization. The purpose of the “Practice Tips” column is to provide practical advice that is relatable and (hopefully) fairly easy to implement in member practices using resources that ACP or others have available.

Dr. Miller's observations regarding the high degree of frustration with prior authorization, the visceral reaction it causes in many physicians, and the urgent need to get rid of it are all spot on. The problem is, however, in some ways even more complicated than the MOC issue because it involves multiple payers and players and affects both primary care physicians and subspecialists across the spectrum. As Dr. Miller is certainly aware, prior authorization applies to drugs and devices as well as referrals for testing, procedures, and subspecialty care. It is a top-priority issue for ACP and a key component of the ongoing Patients Before Paperwork initiative.

For example, in February 2015, ACP testified to the National Committee on Vital and Health Statistics on operating rules for prior authorization. Peter Basch, MD, MACP, Chair of ACP's Medical Informatics Committee, testified regarding the issue of administrative burden, including prior authorization, and how technology could provide a solution such that time-consuming, often daily defense of orders by physicians and their staff would be unnecessary. Dr. Basch said, “ACP strongly believes that, wherever possible, prior authorization should be avoided by using technology to bring transparent, accurate, and actionable cost and insurance coverage information to the point-of-care.”

In 2014, ACP advocated for reduced burden related to prior authorization of medications in a letter commenting on the Medicare Physician Fee Schedule. The letter read, in part, “ACP recommends that formularies should be constructed so that physicians have the option of prescribing drugs that are not on the formulary (based on objective data to support a justifiable, medically indicated cause) without cumbersome prior authorization requirements.” In ACP's 2015 comments on the Medicaid managed care rule, ACP stated, “Prior authorization procedures should only be required of practices with a documented history of overuse or inappropriate use of services. Doing so will decrease the administrative burden and cost on practices that provide necessary and efficient care.”

ACP is also working with several primary care, radiology, and imaging groups to advocate for evidence-based “appropriate use criteria” for certain high-cost imaging, whereby payers (including Medicare) would agree on a set of criteria for specific tests and procedures that would not require practices to jump through hoops every time they order them. ACP also advocated for reduced burdens of prior authorization in its letter regarding the 2016 Physician Fee Schedule. While these examples represent only pieces of the larger prior authorization problem, ACP definitely recognizes that the problem is significant. ACP is trying to tackle different aspects from different angles and will continue to do so.

ACP staff takes comments such as yours very seriously. We hear you and will continue to work with our colleagues in the medical community to find practical solutions that can take the burdens off practicing clinicians while retaining assurance of high-quality, high-value care.

Ultimately, it is our mutual goal “to modify, reduce the burden of, or hopefully, maybe, end the current prior authorization process.” We continue to seek feedback and ideas from members about how we can address the issue of prior authorization and other administrative burdens. As more payers move toward alternative payment models, not the least of which is Medicare through the new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) law, we hope that some of the hassles associated with fee-for-service medicine will go away because we will be measuring outcomes and patient experience, rather than how many brand-name drugs or MRIs patients receive.