Welcome to prior-authorization hell

“What diagnosis do you want to use for those ear drops you sent on Mr. Johnson,” Jenn texted me. “ICD-L21.8 for seborrheic dermatitis?”

Sigh. Welcome to prior-authorization hell.

These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10-milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus)

Jenn tried submitting this new diagnosis without success. She then noted that this medication was supposed to be authorized without need for authorization, so she called the pharmacist, who ran the 30-milliliter bottle through the computer system and the medication was authorized. That size bottle goes for $27 cash.

Rob bangs head on wall.

But Jenn didn’t yell. She didn’t say any profanity (that I could hear). Jenn’s a saint. She lost 30 minutes of her life to this nonsense, as did the pharmacist. As for me, I just got a little extra blood pressure points, a little acid corrosion of my stomach, and a stronger desire for beer when I get home this evening.

While my practice doesn’t accept money from insurance companies, we do serve our patients for the sake of their health. This means that we advocate on their behalf in a system that seems hell-bent on making care less accessible. Prior-auth hell is one example of this wall that has been built up between people and reasonable care. Electronic medical record hell, pharmacy trickery hell, specialist non-communication hell, bloated hospital gouging hell, media non-story hype hell, and opportunist alternative medicine hell are all contributors to the hell-fire heat we are all feeling.

By “we” I don’t just mean the people working in my office. I also don’t just mean primary care office workers. The pharmacist, the patient, and even the insurance company minions were drawn into the crisis over a $15 medication authorization. Would you want the job of explaining the reasoning behind denying a 10 ml bottle and accepting a 30 ml bottle? All-in-all there are countless hours sucked from people’s lives across the country each day, sucked away with the end product being: nothing. No, not nothing, the end product is worse than nothing; the end product is poorer care for people who need it and increasingly embittered healthcare workers.

Nobody benefits from this. Nobody is making more money because of this prior authorization for a 10 ml bottle of antifungal. The way the system works, it’s not that the insurance company refusing to pay increases its profits by denying cheap generics. Their benefit comes from having a “cost control” plan in place to prevent unnecessary or inappropriate medication cost. As is often the case, the inefficiency of the process and the resultant increase in cost is passed through the insurance company and sent to the person writing the checks (whether individual, business, or government institution). The idea of “cost control” makes some sense (nobody wants expensive, unnecessary drugs to be paid for without question), the total chaos of the system results in everyone gaming that system to pass the buck up to the person paying the bill.

So what can be done?

The biggest thing is to stop using insurance to pay for cheap things! Automobile insurance does not cover routine maintenance, or even expensive repairs. The car owner is expected to pay for these out of pocket, with no consideration if they can afford it. While this results in hardship, I’ve heard of no one clamoring for “MediCar for all” (universal auto coverage for all car service). So why are we paying insurance for primary care? As hard as some try, primary care docs will never give anyone a huge bill for their care.

Primary care, generic medications, and even simple emergency care don’t need to be expensive. They are only expensive because of insurance hiding the cost and putting a layer of administrative people between the patient and the care they are getting. If pharmacies competed for your business by publishing prices of drugs, what would happen to those prices? The same is true for simple emergency care and primary care.

I know that because I’ve lived in that kind of system for nearly seven years. My patients know the price I charge for everything I do, and we don’t do something before getting their agreement on the price. Often, that’s not a difficult thing to get from them. “That medication is 75 cents per month,” or “The thyroid test costs $4” is not often met with anything but chagrin over the low price. My goal with these low prices is to make it so my patients can’t afford to stop paying my monthly fee. Because they are paying me directly, I am aggressive at trying to keep them as my patient by cutting cost and improving service. This is good business for me.

So why not push that to the rest of the cheaper side of medicine? Insurance payment is why we have $100 hemorrhoid cream. It’s why a 100-year-old medicine for gout still costs $70 per month. It’s why generic ear drops for swimmer’s ear still cost over $100. It’s because someone is still willing to pay those ridiculous prices: the insurers.

The direct pay pricing can even extend to more expensive things. There is a surgery center in Oklahoma City that accepts only cash payment and posts the cost of procedures online. Doing this will significantly reduce the overall cost of these procedures (and patients can go back and recoup money from insurance if needed). While this doesn’t work all the time, the reality is that our healthcare crisis (and yes, folks, it is a crisis) doesn’t necessarily require more or better insurance to fix it. Perhaps we need to stop insuring things.