Rheumatologists! Unite Against the Formulary Police!


Prior authorizations have begun to spread pandemic-like from high-cost biologics to treatments used routinely in rheumatology. The time burden on rheumatologists is insupportable, contends the author, who says it's time to take action.

[[{"type":"media","view_mode":"media_crop","fid":"32176","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3955334910663","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3404","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 213px; height: 109px; margin: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]I used to treat some fighter pilots. They all hated paperwork. One of them told me, “Doc, when the weight of the paperwork exceeds the weight of the airframe, you are finally cleared for takeoff.”

I laughed at the absurdity of this, and dismissed the hyperbole as fighter-jock bravado.

Today I appreciate the metaphor, because the same paperwork burden now hinders us physicians from fighting disease.  In thousands of practices across the country, many times a day, insurance company pharmacy benefits managers (PBMs) either demand that we justify our therapeutic choices by asking for prior authorization (PA) or outright refuse to provide certain drugs. (See for instance this letter from two members of Congress to Express Scripts about some of the biologics used in rheumatology.)

PAs relate to “step-edits” or “fail-first” rules, which force patients to try cheaper or “preferred” drugs before the PBM will pay for an expensive treatment. Camouflaged as “quality care,” these delaying tactics are really cost-control measures.

Initially PBMs required PAs only for the “big ticket” items like chemotherapy or biologics that cost hundreds or thousands of dollars a month.  Most of us accepted the necessary evil of these cost controls. After all, the insurance company needs to give the greatest good for the largest number of beneficiaries using finite premium dollars. This may be at odds with my desire to do the most good for the individual sitting in my exam room, but the model is at least philosophically defensible.

Now the PA principle has spread to even staple generics: standard-of-care medicines like meloxicam, cyclobenzaprine, azathioprine, and methotrexate. Are all patients with rheumatic disease too expensive to cover?

Rumor has it that the largest insurer in my state will propose requiring PAs for almost everymedication we prescribe, from inexpensive generics to the most costly biologics.

Hearing this, I canvassed my rheumatology colleagues, from solo practice to big group to university mega-clinic. Although each doctor had a favorite personal gripe with PAs, several consistent complaints emerged:

1. PAs are being demanded for inexpensive generic medicines. Despite firm opposition from the American College of Rheumatology in numerous position papers, many PBMs insist on switching patients from one NSAID to another, just because of a quarterly change in their formulary. (One insisted that tizanidine is [[{"type":"media","view_mode":"media_crop","fid":"32177","attributes":{"alt":"formulary police","class":"media-image media-image-right","id":"media_crop_2650587792314","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3405","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 143px; height: 147px; margin: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]safer than cyclobenzaprine for my 77-year-old who strained his shoulder playing tennis. That’s not what my pharmacology textbook says! But no amount of science will dissuade the formulary police.)

2. PAs take too much time and effort. Since each PBM has different criteria, completing PA requests is more complex than reciting the complement cascade backwards. A single PA for one patient may take 30 minutes or more of chart research, form completion, form resubmission, and phone calls. My quick survey suggests that PAs currently require 0.77 full-time employees per practitioner: 3 employees to do nothing but prior authorizations for 4 prescribing clinicians! Few practices can afford this expense.

3. Denials and delays impede patient care. This speaks for itself. The longer an insurer can string out an approval, the fewer days it has to pay for the medicine. Many plans explain the delays to patients by saying “the doctor didn’t fill out the form right” – inexcusable blame-shifting!

4. Clueless clerks tell doctors how to prescribe. This is my pet peeve. Last month I was told that I must use three aromatase inhibitors to treat a man with rheumatoid arthritis before the PBM would approve methotrexate.

“What? Give tamoxifen to a man with RA? Where did this policy come from?” I inquired incredulously.

“We got it from a drug policy guide on the Internet,” replied the customer service representative (honest and cheerful, but unrepentant). This is not only medical malpractice; it is morally indefensible.

My respondents had a host of other complaints (some unprintable). But all agreed that the PA process as currently imposed on rheumatologists is simply unacceptable.

Since PAs probably won’t go away, how can we reach an understanding with PBMs that will meet patient treatment needs while allowing us to be good stewards of the health care dollar? I propose that any action be based on three principles:

1. Every PA pathway, step-edit, or fail-first policy mustconform to current standard of care practice guidelines. Don’t ask me to use sulfasalazine as a prerequisite to TNF-α therapy in axial spondyloarthritis if the current published guidelines say it doesn’t work! I should not be forced to practice substandard medicine because of a PBM’s cost constraints, or because their clerk can’t read medical journals.

2. Transparency is critical. If a PBM creates a PA, it must be clear and applicable to the prescribed drug. (Please don’t tell me Remicade is a Part D benefit or methotrexate is part B). It must also be willing to offer unconditional approval when criteria have been met. (The PBM clerk must actually read the form that says their preferred step-edit drugs have already been tried.)

3. Timely response is mandatory. If a PBM requires a PA, they must provide an answer within a few days, not weeks or months. Diseases damage joints while PBMs decide whether your patient (who paid a premium for care, and deserves to get it) is worth treating.

It’s all well to state principles, but how can we achieve them? ACR position papers are not enough. Hours on the phone cajoling insurance clerks is not the solution. Policymakers (insurance and government) won’t listen to experts like rheumatologists, because they see us as the problem: We write the expensive prescriptions.

It is time to inform and empower our patients to pressure politicians and PBMs to implement these simple principles. Organizations already exist to promote this kind of advocacy (see http://failfirsthurts.org/ffh/), so we don’t have to start from scratch.

Draft a letter to your patients and hand it to them as they leave your office. (Feel free to copy or modify my draft published here.) Briefly explain the problem with PAs, direct them to an advocacy site, and ask them to do themselves (and you) a favor by writing their insurance company and their legislators about the roadblocks to reasonable care that PAs impose. (I've also supplied draft language for a letter from patients to their legislators. You may want to add specifics regarding a particular problem with reimbursement.)

The policy makers may ignore the pleas of dozens of doctors. But they will listen to thousands of patients (a.k.a. “beneficiaries” and “constituents”).

(To print or save the draft letter to your patients or the draft letter from patients to legislators, click the printer or PDF icon in the black bar at the bottom of the screen.)

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