“I’m Calling about Paul”

February 25, 2019

Paul has been coming to our dermatology office for years.  He has painful psoriasis; after years of trying different medications he finally found one that controls his symptoms.  Then Paul changed insurance companies in the middle of his treatment.

His new insurer denied the effective medication.  They wanted Paul to fail first on an older and more toxic medicine or try a topical.  The dermatologist I work for knew this wouldn’t be a good switch for Paul, so I called and submitted records outlining his treatment history.  I showed how Paul already tried what his insurer was proposing. But they wouldn’t be swayed.

Then there was Mary.  She also has psoriasis, and she’s trying to start a family.

So the doctor prescribed her a new biologic for treating psoriasis that’s safe for pregnant women.  But Mary’s insurance denied it. I tried to reason with the insurance representative, but before approving the biologic he wanted proof of pregnancy or confirmation that Mary was breastfeeding.  In the end, Mary opted to stop taking any medicine just to safely start her family.

And there’s Shelby.  She has been effectively treating hidradenitis suppurativa for years with the same medication, but her insurance still requires authorization every six months.  We all know gaps in treatment hurt patients. Yet sometimes prior authorization paperwork, even for re-authorization, can result in medication delays for weeks, allowing unpleasant side effects to flare up again.  

Not wanting Shelby to have this experience, I submitted her reauthorization paperwork a week ahead of the six-month mark.  Two weeks later, we were still waiting. Meanwhile, Shelby’s medicine ran out, and the office didn’t have any samples to hold her over.

Let me be clear.  I understand that some medications are expensive.  I get that insurance companies must review claims. But excessive, inappropriate use of prior authorization and step therapy hurt Paul, Mary and Shelby, and thousands of other patients like them.

Sure, older, cheaper medications might save insurance companies money upfront, but they cost patients in other ways.  Some treatments force patients to take time off work or school because of side effects, for example. Missing work can create problems with their employers, not to mention the hardship of missed income.  Meanwhile, discomfort from poorly controlled symptoms can make it hard for patients to sleep, making it hard, in turn, for their spouse to sleep. It can be uncomfortable, even painful to wear certain clothes.  
Health plans need to understand this.  And they need to do better by patients.  

That might mean accepting early paperwork submissions to help patients avoid lapses in medication.  Offering a simple, straightforward exemption process. Or maybe supporting continuity of care by recognizing when patients have already satisfied a fail first requirement with their previous insurer.  

Until insurers are willing to put patients first, health care professionals like me will stay buried in excessive paperwork, long hold times on calls to insurers and redundant questions by health plan representatives who don’t know enough about the patient or condition in question.  

And patients?  They will have to keep waiting for their medications—or be forced to try treatments they’ve already failed on, yet again.

Courtney Clayton is a medical assistant for a dermatologist in Washington, DC.

This post is part of IfPA’s “By All Accounts” blog series.  Each month, a different guest author – and a different story – adds a new piece to the common narrative of how insurance practices meant to control costs are instead hurting patients.

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