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Prior Authorization and Choice of Drug


Payers (insurance companies) increasingly require prescribers to convince them of the medical necessity of the drugs they recommend to their patients before they will pay for those drugs. This process can take more than an hour for a single prescription, and does not always result in approval.

Even when prescribers can have clerical staff assist the process can be costly. It seems likely that this would lead to choice of a drug that costs a patient little even with no reimbursement, rather than one that costs the prescriber many times more in time or payment to office staff.

In some cases cheaper drugs work just as well as more costly ones, and we all benefit in lowering of premiums. However, choosing a drug with substantial adverse effects may cost us all more in the long run.

I believe we all must work to contain the costs of medical care, but payers could markedly improve this inefficient process by leaving the prescriber out of the loop. They could accomplish this by accessing the patient record directly to make their decision. Although the provider would still have to justify their recommendation, they could avoid time-wasting telephone calls and appeals.

Such a practice still fails to solve at least one problem: If the payer fails to authorize reimbursement, the prescriber must recommend an alternative drug and discuss that drug's use, risks and adverse effects. Ultimately, prescribers may have to review several drugs with the patient before embarking on the prior authorization odyssey.