Just a little rant.

In the last few days I have had several of the following experiences. They are not unusual, just unusually concentrated in time. I have altered things, but this is representative.

I saw a patient some weeks ago with a significant depressive disorder. Not get-thee-to-a-hospital severe, but also not a time to mess around. He also has chronic pain. There are a set of antidepressants that work for chronic pain. There are a subset of those that have fewer side effects. There is one in that subset that can be titrated up to a maximum dose in two steps (rather than the three or four others might take). I run through all this with the patient and the choice of pharmacotherapy is made. Yay team! We’re on the road to wellness.

The next morning, in my box the pharmacy fairy has deposited a request for “prior authorization” for said medication. Which also means my poor patient showed up at the pharmacy and couldn’t pick up his medication.

I get somebody on the phone. She is neither a pharmacist nor a physician. She simply asks the following questions: “What was the medication?” “What was the strength? (i.e. dose),” and “Have you considered anything on the formulary list?”

Noteworthy in this conversation were:

  1. When I said I had decided on the medication because reasons, there was no corresponding, “You know, Smurfatrol XL (little R-in-circle thing) might do about the same thing and it’s more affordable.”
  2. The reasons clearly did not matter either. I could have said, “Smurfatrol causes Malignant Lilliputian Cyanodermia, and that risk is unacceptable in this patient,” and the person on the phone would be none the wiser.
  3. She was utterly stunned when, just to be a good sport, I asked what was on the formulary list. I’m not sure anyone ever even asked before.

In other words, this was entirely form, with zero content. My patient couldn’t pick up the medicine because I had to first call someone in a call center to read off exactly what was on the prescription

A week later, the patient came in and told me after all that, he hadn’t been able to pick up the medication from the pharmacy and had not started the treatment. So much for being able to move faster.

Experience 2:

I have a patient who is taking 150mg of ectavan (not a real drug), and I’ve told her to use 1 ½ tabs of 100mg each. I did this because the only other way to get a 150mg dose would be to prescribe 50 & 100mg tablets; which would wind up being more expensive overall and make the patient pay two co-pays. I always write prescriptions as generic.

With me so far?

She’s been taking this medication for months, when again the pharmacy fairy drops a love note in my box in the form of a 1 – page fax form for authorization. Mind you, this medication is exactly the only one in its class. There is absolutely no other medication available on the market that does this. It has also been approved for months on end.

I dutifully fax this waste of my time, only to hear two days later that was disapproved.

I am now, officially, p@#&ed off. There is attempting to control medical care costs, and then there is just straight-up $%#$ing with me and my patient.

I’m back on the phone now.

Again I go through the dance, and at the end of that we have this exchange:

“Did you consider the generic Vantec?”

“I have always written the script as generic. I don’t care what brand it is.”

“OK. We can approve the generic.”

Success! I didn’t even have have to imply an abnormally intimate relationship between the medical director and a close relative! Not out loud, anyway. Problem solved.


A day later my patient shows up only to have the pharmacy tell him he can’t pick up the prescription.

Care to know why?

No, you really, really don’t.

My patient finally walked away with two co-pays, having to take 3 capsules per day when previously she had one copay and 1 ½ pills per day. If you look up these meds, this new regimen would cost $500/month. The previous one costs a hair over $300. So maybe the payor figured some kind of sweetheart deal, but I’m guessing they’re not getting the 40% discount it would require them to break even on that. Not to mention the time they have to pay the people to read faxes and listen to physicians implying abnormal family relationship dynamics for their medical directors.

Pervading all this is the sense of absurdity. I am a physician who, by and large, takes care of poor people. I think a lot about what they can take and what they can’t. I spend a lot of time thinking of the cheapest thing I can prescribe. People don’t need one more reason to not take their medicine.

I see insurers creating barriers to health care which then require health care institutions to produce countermeasures which then cost more and get taken out of someone else’s pocket. The costs of all this prior authorization stuff, in terms of payors’ staffing and such; as well as doctors’ time and office staff, is probably in the low tens of billions from what I have read. 

One would really, really hope that all this crap would be worth it. Personally, I can’t tell it is. It seems to me that the system of cutting medical care into little monetizable widgets and then trying to force people to use fewer widgets hasn’t changed much, except to create new jobs defining and pricing the widgets. While all that’s going on, the prices of the widgets keep rising way faster than any efforts to reduce their use. It looks to me like whatever real savings we get out of this may just as well be due to people just not getting treated.

It’s mutually assured destruction, applied to health care. This thing is coming apart at the seams.


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