Prior-authorization reform: Getting the right medicine at the right time

You've been taking a medicine for years. You tried several, but this one works well, doesn't give you side effects and is on the formulary for your insurance. You go to the pharmacy on a Saturday for your usual refill, and the pharmacy tells you instead of your usual $10 copay you owe $250. Your formulary has changed.

You are shocked. What happened? Most likely a different drug company gave your health insurance a better price for its drug this year, not because the new preferred drug is better.

It's Saturday. What do you do? You can stay on your usual medicine and — if you have the cash — pay for it. Or you can switch to the new medication, but there is no guarantee that it will work as well or be safe for you. You may need blood tests or office visits to make sure that the new medicine is working, and that will cost you time and money. Besides, you may have to change again next year.

If you hope to stay on your same medicine but with your previous coverage benefits from your insurance, that is when the prior-authorization process begins — on Monday, when offices are open.

Nurses whose time would be better spent helping patients with clinical concerns spend hours on the phone to try to get permission from the payer to cover a medication you have previously taken, under the same insurance, for years. Each January is dreaded, as repeating the identical paperwork process is demanded.

Companies often suggest alternate medications inappropriate for the clinical situation. The types of medications — for example, insulin — may be changed back and forth multiple times in the same year, leaving patients stranded at the pharmacy counter on repeated trips while their blood sugar climbs.

Elderly patients are bewildered by a jumble of constantly changing medications of new names, colors, shapes and sizes, leading to potentially serious medication errors at home. Patients with life-threatening infections may have their antibiotic delayed for days by the negotiation process for the correct antibiotic, even though germs don't put their attack on hold over the weekend until offices are open.

Drug plans would have to say which drugs are on the formulary and what the cost to you is at least 30 days before open enrollment. Authorizations for nonformulary coverage would remain as long as you remain enrolled — no need to repeat the process each January. You would have 60 days of coverage to switch to a new formulary medication if your current drug is no longer covered. Drugs on your plan's formulary could not be subject to prior-authorization requirements. Plans would be required to tell the prescriber what alternatives would be covered; currently, we are left to guess, with even more back-and-forth phone calls.

This is not just a Minnesota problem. The American College of Physicians, the national organization of internal medicine physicians, has launched Patients Before Paperwork, an initiative to reduce administrative and clerical aspects of medical practice to what the patient needs, instead of drowning medical care in a sea of bureaucracy.

Passing these bills can make Minnesota a national leader in health care yet again.

These bills do not call for the abandonment of formularies or for ignoring real medical costs. However, the true global cost of arbitrarily and frequently changing medications needs to be considered; it is time to streamline the prior-authorization process. These bills can improve patient health and safety, decrease the frustrations of many patients, and reduce office hassles that impede patients' access to clinicians when patients need them.

People dealing with serious health issues have enough struggles. Let's reduce adding to their daily challenges by moving forward with sensible prior-authorization reform. Ask your legislators to support H.F. 1060 or S.F. 934.