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Patients endangered by lack of transparency

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POSTED: April 14, 2011 10:49 a.m.

One of the most widely debated topics today is health care. Between physicians and patients, the dialogue is markedly louder. In an ideal world, physicians successfully could manage their patients’ individual health, based on years of medical training using prescribed treatments determined by examinations, appropriate tests, diagnoses and patient histories.
However, that is not always the reality. Health care consumers and their providers have to consider costs, but we still need to make the best medical decisions possible. Quality care cannot exist without access and choice. Unfortunately, insurance companies are interfering with quality care by implementing steps that force patients into choices that are not always best and by cutting off access to treatments at an alarming rate. For many patients, this can mean the difference between a positive outcome and a trip to the emergency room.
One of my patients recently asked for a generic medication for her epilepsy due to cost pressures from her insurance company. Very shortly afterward, she suffered a significant seizure that sent her to the emergency room. Aside from the trauma, pain and long-term damage to her health, any “savings” from the medication switch were negated by the expensive hospital visit.
To make matters worse, when the same patient went to the pharmacy to pick up the prescription medicine I originally recommended, the pharmacy informed her that the medicine was not “approved” by the insurance company and she would have to wait for authorization to dispense the medicine. Since the “prior authorization” process can take days or even weeks, she was forced to leave the pharmacy without medicine. A few short days later, she suffered another seizure and was again hospitalized. Now, she is unable to drive for six months due to Georgia law.
I’m not a financial expert, but I know these “cost containment” tactics aren’t resulting in “savings.” This entire episode could have been avoided had there been transparency in the way the insurance company did business. At the point of care – when the patient was in my office – had I been aware of the prior-authorization requirement, I would have been able to provide the information needed to grant authorization, and it would have saved thousands of dollars, a tremendous amount of pain, not to mention the countless hours, calls, letters and faxes on my patient’s behalf.
Unfortunately, this situation is not unique to my patient. A recent study from the American Medical Association found that more than two-thirds (69 percent) of physicians typically wait several days to receive prior authorization for medications, while 10 percent wait a week or more. Since I employ a full-time professional who spends 90 percent of her time addressing insurance requirements, I was not surprised to learn that nearly all physicians surveyed said that streamlining the prior-authorization process is important, and 75 percent of physicians said an automated prior-authorization process would help manage patient care more efficiently.
There is hope on the horizon. Health Information Technology (HIT) holds the potential, through things such as electronic medical records and e-prescribing, to improve the coordination of care and patient safety and to streamline this process in a transparent, real-time and cost-effective way. After all, this was the intent.
The federal government realizes the need for this newer technology as evidenced by the U.S. Department of Health and Human Services awarding our state more than $32 million to further the use of HIT. On a state level, Georgia has an opportunity to make sure the intent of HIT becomes the reality – and we can do that by putting policies in place that will protect physicians and patients well into the future, as technology becomes second nature.
I have utilized this technology, including e-prescribing, in my own practice for the past two years. While my system continues to advance with each “upgrade,” there is no way for me to know what treatment an insurance company ultimately will approve or deny or how I can complete a prior authorization for a patient. Our elected officials should take action to ensure more timely prior authorizations, giving patients more clarity in the physician’s office, certainty at the pharmacy counter and safety once they leave.
Neurosurgeons can do arthroscopic brain surgery, my iPhone can tell me who is singing the jingle on my radio, and I should be able to receive information that will enable me to make the best treatment decisions for my patients. As Georgia takes steps to protect patients, electronic prior authorizations should be a top priority. It may be one of many “fixes” to the health-care system, but it is one that will allow patients to get the treatments they need while keeping from incurring additional costs due to emergency-room visits and hospitalizations.

Mayville is a neurologist in Macon and a national board member for the Alliance for Patient Access.

 

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