Clinicians provide best practices for helping patients access medications
“Prior authorizations are here to stay,” Jeffrey S. Williams Jr., OD, Dipl ABO, told Primary Care Optometry News. Optometrists must learn how to navigate prior authorizations in order for their patients to receive the branded medications they are prescribed, he said.
“I don’t think you could find too many practices that would say PA is a positive aspect of what they do every day,” Connecticut practitioner and PCON Editorial Board member J. James Thimons, OD, FAAO, told PCON. “But you will find that most practices are absolutely dedicated to getting the best for their patients and will do whatever is required ... understanding that now there is a burden on the doctor that wasn’t there before.”
Darrell E. White, MD, has been vocal about the constraints the prior authorization (PA) process puts on his practice and the complicated, profit-driven path determining prescription medication pricing in the U.S., in his column, “Follow the Money,” in PCON’s sister publication, Ocular Surgery News.
A big interference in patient access to medication is the pharmacy benefit manager (PBM), said White, who practices in Ohio. Originally, PBMs took over all responsibility from whoever paid for medication, he told PCON. Initially they were paid a fee for that service, then it became a percentage of the savings, “then it became something totally different.”
Now, PBMs pay list price to the pharmaceutical company, White wrote in his blog. But “before this happens, the pharma company has negotiated to pay a rebate back to the PBM, ostensibly for the privilege of a more advantageous position on the formulary.”
The rebates are a percentage of the drug price; the higher the price, the greater the absolute amount of money flows to the PBM, he said. “In this perverse way, the system encourages higher prices. Because your patients pay a percentage of the ‘negotiated’ price, this is how they end up with an astronomical co-pay,” White wrote. “The notion that an insurance company or PBM is negotiating discounts from anyone on behalf of the insured patient is a fantasy.”
In addition, “an insurance company or PBM will do whatever it takes to get providers to prescribe the medication that brings it the most revenue, not necessarily the least cost,” he continued.
White sees PA requirement as a “herding” phenomenon.
“Whether the PBM is doing it to reduce costs or profit from the individual sale of pharmaceuticals – that’s all PA is – it’s herding people to a particular destination,” White told PCON.
There has been little external governing over the PBMs’ relationship with pharmaceutical companies, “but there may be some coming,” he said.
Patients suffer because they cannot get their medicine right away, White said. “They have massive amounts of anxiety, which is created by the simple possibility they may need to spend the outlandish prices that are presented to them, and the pain is also felt by any physician or medical organization responsible for getting prescription medicines to a patient.”
White’s practice spends 40 hours per week working on PA-related paperwork alone.
“I have four doctors in my practice and 19 full-time employees,” he said. “We spend one full-time employee’s worth of hours each week on nothing but paperwork to get our patients the medicines they need.”
PA service providers
Williams, who practices on Long Island, New York, recommends using a full-service PA process provider to any medical practice struggling with the challenge of PA. His office uses PARx Solutions.
Cover My Meds is another popular option among the eye care community.
Before adopting the service, navigating PA in his office was messy, Williams said.
“It was a lot of blank forms from the 10 different, respective insurance companies that we accept. You’d have to fill it out, fax it and pray that it was approved. If it wasn’t approved, you’d get a 15-page fax back,” he said.
His staff would manage lengthy spreadsheets to keep track of patients, various dates and follow-up milestones.
“It was a lot of wasted time and frustration,” Williams said.
In a recent PCON article, Williams outlined how practice owners can assess the impact of the PA process on their practice and weigh the systems available that are intended to help. He wrote that a good starting point is looking at the individual PA process challenges at the practice. These may include:
- How often are prescriptions denied coverage because a PA is required?
- Are your patients’ managed care plans frequently changing the criteria for approving coverage for your prescribed medications?
- How important is it for your patients to receive the specific medication that you originally prescribed?
Next, he suggested appraising the current burden on the optometrist and staff in managing PAs:
- How many hours are spent on PAs including: hunting down the correct form, completing and submitting the forms and spending time on the phone with managed care plans?
- How often are submitted PAs denied by the plan?
- If denied, how often does your practice appeal the decision with the plan?
Finally, he suggested considering the PA process options: using a form-based service or a full-service provider.
Providers also have the option of going it alone, which Williams says may require a member of the staff focusing solely on PAs or carving out time from multiple staff members.
After using the service, not only are approvals accomplished faster at his office, but through the experience, his staff has learned many of the protocols for the different insurance requirements.
“It went from chaos and confusion and shooting in the dark to seeing more patients daily,” Williams said.
Selina R. McGee, OD, FAAO, works with PARx and Cover My Meds in her practice in Oklahoma.
“We use both, depending on the drug,” McGee said in an interview. “They don’t do the PA for us, but they help us navigate the PA and greatly reduce the amount of paperwork necessary to obtain a PA.”
The onus is still on providers to make sure patients get the medication they need, she said.
“You have to do your homework on the front end and, if you follow certain steps, the patients won’t be upset with you about a surprisingly high drug cost,” she said.
The challenges to prescription access are threefold, according to McGee. First, money is certainly an issue.
“I’ve had patients in the past who buy the husband’s medication 1 month and the wife’s eyedrops the next month,” McGee said. “It’s terrible to put someone in that position.”
Second, it becomes a staffing issue and a question of who is going to deal with PA in the office, “which is frustrating,” McGee said. “You now have one person tied up doing something that is not where their talents are best utilized, but you have to do it.”
Last, there are many different insurance plans with varying coverage. “Patients expect us to know all of the different plans, and most patients do not understand them either,” she said.
“If we can cut out the middle man, that would be great,” McGee said. “It’s all perpetually in motion, which makes it even trickier.”
The industry can be a resource, she said. “When they know of the issues, they get it right, but that’s a challenge in itself.”
John M. B. Rumpakis, OD, MBA, who has worked within medical coding and compliance for 20 years, recommends that providers designate a single point of contact in their office for the carriers. He also recommends a repository in the office to maintain the updated information that is accessible to everyone in the office.
Providers should employ technology where applicable to help maintain the rules, whether an online source or a printed resource, he said. “If you’re aware of the rules and policies ahead of time, it allows you to communicate more effectively with the carrier and the patient.”
He said pre-communication is essential. Telling a patient what they need and what their insurance covers can help prevent many problems.
“I think that ODs, unlike MDs, have a more difficult time understanding that the health care system of today is purposely shifting the cost of medical care to the consumer of the medical care,” Rumpakis said. “That’s a reality that ODs have a difficult time accepting.”
Pharmaceutical companies can be a resource
Matt Maguire, senior director of access marketing at Takeda, described the company’s various programs and resources that provide assistance to patients.
Takeda’s Ask iiris patient-based hub provides three essential things for patients, he said.
The first step for many patients is a benefit investigation piece, which can be completed by phone, fax or online, he explained. If Ask iiris determines that a PA is necessary, the company will provide that information to PARx Solutions. The office can then use PARx Solutions to get the PA completed and sent to the insurance carrier.
They also look at out-of-pocket options for the patient. “The most obvious one is a transition to our copay card. Commercially insured patients could pay a minimum monthly fee for Xiidra,” Maguire told PCON. “Through our patient assistance program, if a patient meets a certain income level he or she could get the drug for free,” he said.
A new program, which was added in October, gives patients the option to have Xiidra (lifitegrast ophthalmic solution) 5% delivered to their home by PillPack, an independent full-service pharmacy. The prescriber needs to select PillPack Pharmacy in the EMR as the pharmacy.
“PillPack delivers to all 50 states, which was huge to us, and it is in-network with 95% of payors. We have received positive feedback with that option” Maguire said.
Another resource for Xiidra is through the field access manager team. “They differ from a sales rep, who would go into offices to discuss Xiidra clinically. This team is dedicated to purely educate on what PA criteria is required by the payor,” Maguire said.
Marcy DeWalt, director of optometric professional relations at Allergan, cited RxHope.com, which helps patients who are underinsured. Patients can receive free medication if they meet certain income guidelines, she said.
Allergan has patient savings programs that can minimize deductibles and reduce prescription costs overall for its eye care products.
DeWalt said CoverMyMeds and PARx Solutions have an 80% approval rate for all branded medications, and she recommends that offices work with an online PA service, “to streamline prior authorizations and help take care back into their own hands, ensuring patients get the medication that was prescribed.
“It does require someone in the practice, a point person who is educated to handle all PAs and gets really good at it,” she continued. “It’s much more efficient than a practice that doesn’t use these services or has people not so familiar with using them.
“At the end of the day, Allergan is committed to partnering with physicians and staff to help get patients the appropriate treatment they need,” DeWalt added.
Thimons hosts a “lunch and learn” at his office with the pharmacy representative when they take on a new product.
“I make sure the rep explains to my staff all about the product in our space,” he said. “They help my staff understand who is going to pay and who isn’t and who needs to go through this portal or that portal first.”
Specialty pharmacies are a way to circumvent the system as it is right now and an effort to, “go back to the future,” White said.
They are typically small, private pharmacies that affiliate in order to gain volume. “In my market there are three or four of them,” Thimons said.
Specialty pharmacies remove a substantial proportion of time-related cost to practices and offer patients and practices the security of a fixed price, according to White. To a degree, these pharmacies can, “insulate the doctor and the patient from all of the behind-the-scenes pain of PA and allow physicians to prescribe what they want to.”
They also help eliminate phone calls from patients who cannot afford their medications, White said.
Companies such as Sun Pharmaceuticals have a pharmacy that fills their product, Xelpros (latanoprost ophthalmic emulsion 0.005%) at a fixed price, Thimons said.
Prescriptions at specialty pharmacies hover around $35 to $50, which is deemed a tolerable amount for most patients, Thimons said. Typically, he finds out about these pharmacies through word-of-mouth. “We all talk about it in Connecticut; there are two or three that do a really good job.”
Specialty pharmacies will also exhaust every possible avenue to get the prescription cost down, Thimons added.
He also spoke about the well-established Bausch + Lomb agreement with Walgreens. By using coupons, patients pay less for Bausch + Lomb drugs at Walgreens. “That relationship has been successful, and they were the first ones to do it.”
For those who work in a large cataract institute, compounding postsurgical drops and having them on hand in the office is a helpful practice, instead of having the patient go to the pharmacy, McGee said. She also keeps fortified antibiotics on hand.
Optometry practices are excited about being involved in therapeutic eye care, but White warned clinicians to go in with eyes wide open.
“It’s hard taking care of dry eye, and what makes it harder is these external forces that you have to address,” he said. “You can be a brilliant clinician ... but that doesn’t mean that you get to abdicate the responsibility to make sure patients get what they need. If you’re doing therapeutic medicine anywhere in eye care, then this is part of your daily life.”
“I’d rather have the PA service tell me what I need to get the medicine,” Williams said. “I look like the hero, the patient gets the medicine, and we’re all happy. And I satisfy the requirements of the insurance policy as well.”
- White D. Follow the money, part 3. Ocular Surgery News. March 15, 2018.
- White D. Follow the money, part 2. Ocular Surgery News. February 12, 2018.
- White D. Follow the money, part 1. Ocular Surgery News. January 25, 2018.
- Williams JS. Prior authorizations: How to choose the best approach for your practice. www.healio.com/optometry/practice-management/news/online/%7b7dfe0b8a-098c-43d9-a723-acc255fb686a%7d/prior-authorizations-how-to-choose-the-best-approach-for-your-practice. Posted December 27, 2018.
- For more information:
- Marcy DeWalt is director of optometric professional relations at Allergan. She can be reached at: email@example.com.
- Matt Maguire is senior director of access marketing at Takeda. He can be reached at: firstname.lastname@example.org.
- Selina R. McGee, OD, FAAO, practices at Precision Vision of Edmond and is president-elect of the Oklahoma Association of Optometric Physicians. She can be reached at: email@example.com.
- John M. B. Rumpakis, OD, MBA, is an authority on medical coding and compliance issues within the eye care field and the founder of CodeSafePlus. He can be reached at: firstname.lastname@example.org.
- J. James Thimons, OD, FAAO, practices at Ophthalmic Consultants of Connecticut in Fairfield and is a member of the PCON Editorial Board. He can be reached at: email@example.com.
- Darrell E. White, MD, practices at SkyVision Centers in Westlake, Ohio. He can be reached at: firstname.lastname@example.org.
- Jeffrey S. Williams Jr., OD, Dipl ABO, is the owner of Sound Vision Care Inc., a multi-location, multi-optometrist private practice with five locations throughout Long Island, N.Y. He can be reached at: email@example.com.
Disclosures: DeWalt is employed by Allergan. Maguire is employed by Takeda. McGee is on the advisory board for Allergan and Shire. Rumpakis is a speaker or consultant with Allergan and Shire. Thimons and Williams report no relevant financial disclosures. White reports he a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.