Blue Cross/Blue Shield Of Vermont Now Using "Prior Authorization" As Evil Tactic; Nationwide Problem

A scheme by health insurers to deny coverage and medication
to patients via bureaucracy has hit Vermont with a vengeance.

My health insurer just caught me up in a type of trap I never knew existed until now. 

It's called prior authorization, and it is a Byzantine, maddening  way for health insurers to deny coverage of important, sometimes life-saving  medical procedures and prescriptions. 

 Prior authorization is evil. It's dangerous. It is being done more and more by "health" insurers nationwide. And ot's hit Vermont with a vengeance this month.

Essentially, it's the insurance industry trying to make medical decision for  patients they've never met. That is, instead of letting physicians who have actually physically examined and worked with these patients do that crucial work.   

This rising tide of  prior authorization denials of medical services has been known to cause poorer outcomes, permanent injury to patients, even extra deaths. 

 This started in earnest this month as  Blue Cross Blue Shield of Vermont  decided to go with a new pharmacy benefits manager called Optum RX, very likely to control costs. 

Prior authorizations are a long standing part of the health insurance bureaucracy, nationally and here in Vermont.  However, Optum has taken this to a whole new level.   Physicians, pharmacists and patients statewide are frustrated and angry, to put it mildly

I don't know how many people this affects in Vermont, but I'm sure it's a lot. I am one of the people being victimized. 

 For many of us Vermonters,  this wave of prior authorizations could mean diminished health care and potential bad outcomes, along with some serious financial implications for people on these medicines. Just as it has in other parts of the nation.  

MY ORDEAL

My story illustrates how all this works. 

I have ADHD, with I manage through medication and behavioral modification.  A key to this treatment are 20 mg time-release Adderall pills that I take twice a day.  I wake up in the morning and take one of the pills. That helps me focus until about early afternoon.  Then things start to go downhill. So I take another one.  That works wonderfully until it's time for me to go to bed.

I've been on this regiment for over a decade. It has worked wonders. One of my jobs in particular requires a lot of concentration and attention to plenty of picky details.  When first diagnosed, my primary care doctor and I worked together to find the best dosage and timing schedule, and after trying various Adderall strengths, this proved to work best.

This all ran great until the first of this month. 

Optum RX, in their infinite wisdom,  decided that I should get by with just one 20 mg dose of Adderall per day, taken first thing in the morning. No second afternoon dose. 

I know this is inadequate. My physician knows that is inadequate. The mental health physician that treated me at the start of all this knows this. My husband knows this. Pretty much everybody knows this except Optum RX

But it doesn't matter. Optum RX has decided it's the way it has to be, based on some mysterious guidance they say they have.  This guidance, apparently to Optum, is much more reliable than my doctor's assessment, and how I know I react to the medication. Remember, nobody from Optum has examined me, or even knows me. 

 I asked Optum them to source their documentation as to why they decided as such. They really didn't give me good answers, at least so far Representatives of Optum have only given me vague references to those guidelines. 

It's interesting that they demand libraries full of documentation but I can't get detailed information from them. Hmmm.

My nightmare with prior authorization is still going on, but I'm lucky enough that so far it's been an expense I can manage, and an inconvenience. My appeal process has little chance of success, but I'm going to soldier on. 

VERMONT CHAOS

I'm surely not alone in this chaos caused by Optum. With the arrival of Optum RX, physicians and pharmacists in Vermont are deluged with messy, complicated and time consuming  prior authorization demands. 

Physicians office must turn over a huge amount of documentation justifying the treatments and medication before they can be covered.  This causes a lot of work for people in the physicians' offices, taking them away from patient care. Pharmacists must spend a LOT of time explaining the issue to confused customer  

The appeal process that is daunting for the physician, and everybody else.  Talk about micromanaging!  One demand from Optum was  that my doctor comb painstakingly through research and find peer review articles that justify my two dose per day schedule, never mind what works for the patient.

My doctor called the demand that he conduct this detailed research "abusive." I absolutely agree with Doc on that

I'm on my own when it comes to the appeal. My doctor's office simply does not have time to do major research projects demanded by Optum.  This is likely the case with many Vermonters caught up in this web.  Most of them likely do not have the time, wherewithal and skills to conduct an appeal.  

I have a background in journalism, so I have experience asking lots of good questions and being especially pesky with them. Most people do not have that past experience. Most people are at a serious disadvantage right from the get-go.  They are out of luck, and will now receive substandard care.

This all happened suddenly, by the way.  Although I started getting letters in the spring, I could not begin the appeal process until July 1. I was given no time to consult with my doctor as my Adderall prescription ran out. 

You should not abruptly change dosages or stop taking Adderall. It can have some serious effects.  I wasn't sure of my rights as far as paying out of pocket goes, so I ran out of my last prescription.  I ended up going a day without my medication.  

Dealing with the missed medicine doses, the lengthy phone calls and research is daunting, especially when I tried to do it without the medication. . Remember, ADHD does not make me great in the organizational skills department. 

Compared to a lot of people in this situation, I'm in good shape. The pharmacy found me some discount coupons so this next month's supply of Adderall will only cost me $77.00. I have the money.

In sum, Blue Cross/Blue Shield and Optum are essentially pawning a lot of work on physicians and pharmacist, hoping they cry uncle and not pursue appeals. Which is how they save money.  My own physician basically says this and I agree with him. 

DAUNTING NATIONAL ISSUE

Prior-authorizations are an increasingly vexing and dangerous phenomenon nationwide. Doctors and activists are trying to fight back.  It's time to start fighting here in Vermont. 

 Not surprisingly, the American Medical Association is fed up with this rising tide of prior authorization demands and is advocating reform. 

The AMA has collected plenty of horror stories about prior authorizations. Here's one:

"'Enough is enough, declared Dr. Irene K., whose private rheumatology practice tracks PA requests over a two-month period. She found a 95 percent approval rate - but some only after four appeals and 'countless time and effort.'"

'The delays it causes prolongs patient pain and suffering and leaves patients vulnerable to permanent joint damage and in some cases organ damage while waiting for this unnecessary administrative barrier to be surmounted,' she wrote."

I want to take note of that 95 percent approval rate after all the appeals. Probably true, but it doesn't include all the patients and doctors who just give up on the appeal process because it's too difficult. That is what is saving the health insurance money.  So what if patients suffer? Cost of doing business, right?

According to a May, 2020 article in The Hill, a 2018 poll of 1,000 physicians conducted by the AMA indicated 21 percent of them said their patients often abandon their treatment as a result of prior authorizations. 

It gets worse. That Hill article paints a painful and deadly picture of prior-auths. I'm not exaggerating deadly. People are dying because of this practice. Says The Hill of that poll of 1,000 physicians: 

"Twenty-eight percent reported that prior authorizations had resulted in cases of serious adverse events for patients. These include hospitalizations, permanent bodily damage or death." 

Also, this: 

"A 2019 survey found that 93 percent of oncologists experienced unnecessary delays in life-saving cancer treatments due to prior authorizations. A study conducted by the Cleveland Clinic found that mortality rates increased between 1.2 and 3.2 percent for every week that the initiation of treatment was delayed."

 Insurers say the prior authorization are done to ensure services and medications and procedures are performed under the correct clinical conditions, but I call bullshit. States already have medical boards and such that discipline doctors who treat patients inappropriately.  

There is some room in my opinion for insurers to have some sort of prior authorization in place. But the current way of doing business is dangerous, wasteful and morally wrong.

Look, I don't think insurers wake up every morning vowing to kill people to enhance their corporate profits. But the weight of ever increasing levels of prior authorization demands seem to be having a fatal effect.

Advocates nationwide are lobbying for reforms to the prior authorization system, but of course they're going up against the powerful health insurance lobby. For what it's worth, you can now count me in as one of those advocates.

This whole experience has put me more firmly into the Bernie Sanders camp of wanting universal health coverage, like most civilized western democracies have.

Sure, there would be bureaucratic bottlenecks under even the best government run universal health care schemes. 

But it has to be better than our current health care system. The prior authorization  craziness is just one more example of a broken system that does nothing else except further enrich billionaire CEOs and their minions. 

I'd rather pay more in taxes for a more fair health insurance system than pay through the nose via private insurance only to be caught in the insurers' webs of obfuscation. The small little state of Vermont can't revamp the entire health insurance apparatus.

But we can work to reform this crazy prior authorization nonsense. Let's get started!