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Third-party payers fail to respect the endocrinologist as a specialist
As a solo practitioner with limited ancillary help, I have to deal directly with third-party payers when a prior authorization is needed to obtain a drug that — in my opinion — is necessary for a patient with diabetes.
During my conversations, I have never been asked if I was an endocrinologist or a specialist. With other specialties, third-party payers utilize the expert’s opinions; eg, only an orthopedist or a neurologist may have the ability to order procedures such as MRIs with many third-party payers.
Patients with diabetes usually do not consult with an endocrinologist unless their diabetes is poorly controlled or complications, such as hypoglycemia, are occurring with their current medications. Because of this, as experts in the field, we more often have to utilize the newer and more expensive drugs in these more complex patients.
However, when I call for an approval for my patient to have one of these newer agents I am treated by the pharmacy technicians employed by third-party payers as a non-specialist. Invariably, a negative decision is given based on the criteria provided to these technicians, and although there is an “appeal process,” I have never once been able to talk to a health care professional (nurse, pharmacist or physician) to make my case and/or voice my concern. Often, the only way for the patient to obtain his medication is for the patient and not the endocrinologist to appeal the decision.
David S.H. Bell
Who are these technicians who have no knowledge of or disregard my abilities and qualifications and who have the power to negatively affect the health of our patients? They are usually not college graduates, have little or no medical or scientific background, do not earn a high hourly rate and are usually certified after a 6-week course followed by a test.
Continuous subcutaneous insulin infusion approvals
Third-party payers, by and large, approve continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, prescribed often inappropriately for patients with type 2 diabetes by primary care physicians and without the input of an endocrinologist. This is counterintuitive because unlike type 1 diabetes, there has never been a study that demonstrated CSII’s superiority over standard insulin therapy or even combination insulin and oral therapy in the patient with type 2 diabetes.
A lot of time and effort in endocrine training programs is devoted to training fellows to be competent in the initiation and maintenance of CSII therapy. The PCP is not trained in CSII and therefore should not be entitled to prescribe or participate in the management of CSII. Often, the initiation of CSII is performed by nurses with the basal rates and bolus insulin dosages that are initially calculated and prescribed by a nurse on a single initial visit. These rates and dosages are often never changed.
However, it should be recognized that if CSII therapy was only prescribed by endocrinologists for patients with type 1 diabetes, sales, profits and the number of pump company sales representatives would all shrink dramatically. Therefore, by approving CSII prescribed by a PCP without the input of an endocrinologist, third-party payers are not only increasing both the cost and the risk of treating patients with diabetes, but also are once again ignoring the qualifications expertise and training of an endocrinologist.
Recognition would bring mutual benefit
When the third-party payers finally recognize that endocrinologists are experts in their field, experts who in most cases should simply be able to state that, in their opinion, the medication(s) or devices that they prescribe are necessary, and those third-party payers respect this opinion, the patient and everyone else will be better served. In addition, if third-party payers would recognize that the expertise and training of endocrinologists is essential for the selection of patients for CSII and that CSII therapy should only be managed by an endocrinologist, significant savings will accrue.
By recognizing the education, training and skills of an endocrinologist, the third-party payers should develop a mutually beneficial relationship with the endocrinologist, a relationship that will result not only in better health and clinical outcomes for our patients, but also cost containment.