Legislative action needed to curtail preauthorization, step therapy policies
Click Here to Manage Email Alerts
Twenty years ago, there were only two P’s present in every ophthalmologist’s consultation room when examining and recommending therapy for an individual: the patient and the physician.
Today, there are three P’s involved in every patient encounter: the patient, the physician and the payer. Even more challenging, every payer’s preference regarding a preferred practice pattern for both the diagnosis and treatment of each of the many ocular maladies we confront every day is different.
In some cases, appropriate diagnostic tests are denied reimbursement, burdening the patient or the physician with increased costs. In other cases, recommended treatments are denied or delayed by prior authorization, limited pharmaceutical availability or the requirements of so-called step therapy in which cheaper drugs must fail before more expensive and often more effective pharmaceuticals can be prescribed. All of these strategies are employed by third-party payers to reduce costs, not to enhance quality of care.
Whose costs are reduced? The patient, the physician or the payer? Patient costs are usually increased because they may have to undergo second opinion examinations, complete extra paperwork or live through ineffective therapies to be allowed to access their and their physician’s preferred treatment. The outcome for the patient is often a delayed or even denied treatment and additional cost in terms of time and money.
The physician is also not a beneficiary. The paperwork required to obtain preauthorization so that their patients can be properly treated demands extra physician and employee time, which adds to practice overhead.
Society also does not benefit. The overall costs of medical care increase as more barriers are placed that reduce access to proper and timely care. Multiple studies have shown that unnecessary cataract surgery is extremely rare and that preauthorization simply adds costs to the physician and patient and delays appropriate treatment.
So, who does benefit from programs such as preauthorization and step therapy for pharmaceuticals? The clear winner is the payer. Patient care that is delayed or denied is a win for the payer at the expense of the patient, physician and society. I suspect this unfortunate situation can only be remedied through legislative or legal action. Our best advocates in ophthalmology are the political action committees and government advocacy programs of our major ophthalmic societies, including the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery.
The forces aligned in favor of the payers are daunting, but part of being a physician is advocating for ourselves, our patients and the society where we live and practice. If every ophthalmologist supports their preferred PAC and their local congressman or congresswoman, we have a better chance to modify the damaging health care polices enacted by some payers.
Collapse
Read more about
Click Here to Manage Email Alerts