A few days ago, one irate physician spent hours on the phone with a pharmacy benefit program. He was trying to get a prescription covered for his patient…that she was already on. What follows is the complete text of the actual letter (and bill for consultation) he mailed them. It is a glorious stance against bureaucracy.

My dear fellow people who may someday need health care:

I am writing today to express my dismay and boundless frustration at your “prior authorization” process.

By way of introduction, I am a board-certified sleep disorders specialist, practicing in an academic sleep disorders center with full accreditation from the American Academy of Sleep Medicine. All of this is relevant background, because most of the medications I prescribe end up in the vile netherterritory of “requiring prior authorization” when it comes to commercial medication management systems like ExpressScripts. I therefore have had numerous interactions with your company, and today I had an experience which deserves telling.

Today, I received an email from the father of a patient of mine whom I’ll call Jane (not her real name). She is a young woman, whom I diagnosed with idiopathic CNS hypersomnia back in October 2010. For those of you reading this letter who may be unfamiliar with this diagnosis, idiopathic CNS hypersomnia is a disorder of the central nervous system, in which the patient feels impossibly sleepy, all the time, and no amount of sleep at night can fix it. It leads to intense psychosocial dysfunction, poor work performance, and, sometimes causes people to crash cars. Many cases don’t respond very well to stimulant medication, but, fortunately, Jane’s did.

At any rate, this is what the email said:

Dr. McCarty, This is Bill Jones, Jane’s dad. Because of her heavy workload, I was asked to email you with a request. James, the Sam’s Club Pharmacist is having trouble getting Jane’s prescription for provigil processed and approved. She is having to buy one pill at a time out of her pocket until her new insurance gets what they need for approval. He said the doctor’s office needs to call this number ESI 1-800-235-4357 for prior authorization for this prescription. If there is anything you can do to help Jane with this, it would be greatly appreciated. My wife and I appreciate everything you do for Jane. If you have any questions or need to talk to me, please call. Thanks again, Bill Jones

At this point, I should mention that, since Jane’s diagnosis, she has been managed with low-dose modafinil, 100mg twice daily. I suppose it goes without saying (after all, I’m a sleep disorders specialist) but I should mention that this diagnosis was made by me, in my sleep disorders center, in my lab, under my supervision. So when I initiated therapy on this patient back in 2010, I recall answering the questions required for “preauthorization” and feeling they were quite straightforward: I was asked her diagnosis (I told them); I was asked if the diagnosis was made by a sleep disorders specialist (check!) and I was informed that the drug was approved for a year.

This is where the trouble starts. Since that time, I have had to undergo the same drill for this patient every year. And every year, the questions and answers are the same. This year was no different, but the weight of this process became achingly clear.

Today I called the number which was provided. After multiple computer-generated menu-choices, I was placed on hold for a full 25 minutes. When I finally spoke to a very nice young lady named Linda, she apologized for the long wait time, checked her file, and apologized because the number I really needed to call was 866-310-3666. I was then transferred to that number, where I was then subjected to a whopping 50-minute hold time, before I could get through to a live person, to complete the “pre-authorization.” This is a short digression, but pre-authorization is imperfectly named, don’t you think? It was pre-authorized back in 2010. At this point, we are now well into re-authorizing, I would say. Which, by the way, is just another way of saying we are re-doing something that doesn’t need to be done. It’s redundant. Doing the same thing over and over. Repetitive. (Annoying, isn’t it?).

Now, I hope you’re still paying attention, because here is the best part: At this point, after having spent an hour and fifteen minutes of my day on the phone ON HOLD with your company, I was asked the same two questions that I answered, way back in 2010:

(1) What is the diagnosis for which the prescription is being written?

and

(2) Was this diagnosis made by a Sleep Disorders specialist?

OK. Hold on. You may have a hard time believing this part, so I’m asking now for the faint of heart among you to take a seat:

The answers were the same as they were back in 2010!

Holy smokes! Who could’ve predicted it?

Now, if I didn’t know better, I would think that your company is deliberately setting up roadblocks to provision of covered services, because you know, deep down, that some of us doctors are just too busy, angry, drunk, or burned-out to stay on the phone for an hour and fifteen minutes to get “authorization” for a drug that has already been authorized in the past. But nope! You guessed wrong in my case. Not me. The longer you kept me on hold, the more determined I became to not let my patient down. I knew that if I hung up,

(a) my patient would be left in the lurch, spending her money on a service that you promised to cover as part of her contract with you (UNFAIR!)

and

(b) I would have to start the whole thing over and call you back (INCONVENIENT!)

So I hung in there, and eventually I was able to talk to a charming young woman in Saint Louis who secured the approval for Jane’s modafinil. For a year.

So I did it. I did it. I gave you the consultation you needed, to make sure that this was still the right drug for this patient. I provided the assurance you needed that this drug continues to be safe and medically necessary.

Don’t get me wrong: I fully accept the proposal that you, Express Scripts* (NB: by the way, it’s charming how the name you chose implies speediness of service! George Orwell could not have done so well!) should exercise some control over the prescribing habits of practicing physicians. I agree that it is in your mandate to help control costs. If part of this mandate requires “checking” with doctors again, to make sure that the diagnosis is correct, I agree, you should have this avenue available to you. But this, my good people, will come at a price. It should be part of your cost of doing business. I am happy to offer my professional consultative services in this capacity, and I will continue to do so at my standard hourly professional consultative rate.

Therefore, for the time that I spent on the telephone, waiting for you to get accept my call to obtain my professional consultation regarding the necessity of this medication, (a consultation you deemed necessary prior to allowing my patient to have access to a medically necessary prescription which is fully covered under her insurance for her indication), I have submitted a bill, for which I expect payment in full (attachment, below). For new prescriptions (ie: those for which you do not have any clinical information at all), I will, in the future, waive this consultation fee, but for subsequent consultations (if the information has not changed) I will plan to do the same.

In the future, I would suggest that you consider the following:

Create an allowance for diagnoses that are durable/unlikely to change with time, and allow longer authorization periods. For a diagnosis such as idiopathic hypersomnia, I would use 5 or even 10 years. Other diagnoses (such as narcolepsy) are lifelong. By authorizing for five years at a time, you will be able to decrease your consultation fees with me by a whopping 500%! Create a telephone system that allows a single number to achieve service. This will allow shorter hold times, and also will reduce your consultation fees. For specialty medications, keep a roster of physicians who, like myself, specialize in the field for which the medication is being prescribed, and cut us some slack. This may cut out a large majority of your consultation fees. This element may require some explanation, because I don’t want to come off as an arrogant jerk (I’m actually a very down-to-earth and likeable person!), but, when it comes right down to it, I know what I’m talking about, and if I say a patient needs a medication, it’s because that patient NEEDS THAT MEDICATION. If your authorization people have an issue with my judgment, I’d be more than happy to go a few rounds with your peer-to-peer reviewer about whether a sleep-related medication is medically appropriate. Again, my consultation fees would apply, but I’m succinct, and I will be happy to provide written documentation of my opinions, complete with literature references, so your reviewers can be educated (and therefore avoid the requirement for more consultations!).

My final words before parting: I had several conversations with colleagues about this incident before I chose to write this sharply-worded communication. I got eye-rolls and groans from all of them. Everyone I interviewed has felt what I’m feeling, and your company in particular has garnered a lousy reputation for giving doctors a hard time. One colleague said (and I quote, verbatim): “They need to know that their service is the worst ever. It’s even worse than Medicaid. In fact, come to think of it, Medicaid is a breeze compared to Express Scripts.”

I think that says it all.

I implore you. Fix this problem before you burn all of us out.

Sincerely yours,

David E. McCarty, M.D., F.A.A.S.M.

Associate Professor, Division of Sleep Medicine

Department of Neurology

Louisiana State University Health Sciences Center

Shreveport, Louisiana

Attachment

INVOICE for SERVICES RENDERED

To: Express Scripts

From: David E. McCarty, M.D., F.A.A.S.M.

RE: consultation fee

Date of service: 10 January 2014

Time in : 10:15 a.m.

Time out: 11:30 a.m.

Total time: 1.25 hours

Hourly Rate: $350

_________________________

Total: $437.50

Payment due upon receipt.

Please remit payment to:

Dr. David McCarty

University Health Sleep Disorders Center

1501 Kings Highway

Shreveport LA 71130

Thanks for your business! 🙂

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Heather’s Note:

Express Scripts is a pharmacy benefit management organization (PBM): They administrate prescription drug programs for insurance companies, either paying for drug claims, or providing cost-saving measures such as mail-service pharmacies and electronic ordering for physicians. In my own experience with Express Scripts, who just happens to be the PBM for my insurance company, I tried out the mail-service prescriptions for three of my four migraine drugs. It was cheaper and convenient: I could get 90 days at a time instead of 30 (although why my local pharmacy couldn’t give me 90, I was never told). Unfortunately, two of the drugs were different—and for me, inferior—formulations. When my side effects increased (somnolence), I switched back to my local pharmacy. After a few months, the price went up. Although I was never moved to write a letter of complaint (my fix was easy and relatively cheap), I still get the drugs at my local pharmacy. I throw out every letter from Express Scripts imploring me to go back. There are many. When I came across this letter through a friend and former colleague, I readily agreed to post it for the world to enjoy. And hopefully spread.