Pizza or insulin: What does our society value more?

Recently, I treated a young patient with diabetes in the hospital. Throughout her young life she had struggled with glucose control, and on this day her struggle left her in a state of diabetic ketoacidosis (DKA). DKA is a life-threatening condition that diabetics often face when their body is  unable to uptake enough glucose, leading to utilization of fat and consequential build up of acidic ketones, which cause blood levels to reach a dangerously acidic state.  DKA has many triggers, such as infection, poor compliance and myocardial infarction to name but a few.

A combination of infection and poor compliance led to her hospitalization. I treated her DKA, but I also invested time trying to understand her barriers to medication compliance. She confessed that her long-acting medicine, insulin glargine, was causing severe burning and stinging at the site of injection.  It is a rare reaction, as glargine is generally very well tolerated.  My solution was to start her on an alternative long-acting medicine, insulin detemir, which she tolerated well in the hospital.  She recovered from her illness, I built a good rapport with her reinforcing the importance of compliance, and discharged her on this new medicine she could tolerate. This could be a new start for her, I thought.

I felt pretty good about myself — for about 3 hours. I soon received a call from the pharmacy explaining that her insulin detemir was not approved. She would need prior authorization. Great, the dreaded prior authorization form, the bane of my (and many other physicians’) existence. Non-standard medicines that are not typically covered on medication plans often require this special authorization.

I immediately called the prior authorization office for approval. Unfortunately I was told that “the prior authorization office was closed on weekends.” Closed! There had to be some way to get my patient her insulin. I spoke to supervisors and made calls after work while in the gym. I simply tried everything but could not find any way to get any emergency override.  I was forced to call the patient and provide an inferior solution to get her through the weekend.

She was approved for prior authorization for her insulin this week, but I am still disturbed by the experience.

This past Thanksgiving, Pizza Hut fired one of its managers, Tony Rohr, for closing his store on Thanksgiving.  (Public pressure caused Pizza Hut to reverse this decision.)  On Thanksgiving, this traditional family holiday, hundreds of stores were open. Yet still, I cannot provide life-saving insulin to a patient in need on holidays or weekends.

Why as a society do we accept such policies? As a physician I’ve had to work on many holidays, and while I’m never excited about being away from family during this time, I understand that it’s part of what we do and what patients need. Why can a company not provide 24/7 hours for critical services? In fact, why do we even require prior authorization? Yes, I understand the health plans need to try to be cost effective and assure that the less expensive solution is provided for the patient with all else being equal, but the concept of prior authorization is another layer of bureaucracy that creates more inefficiency in our broken system.

I know of several creative ways that use technology to provide simple checks to assure cost-effective practices. Why do I need to be on hold for 30 minutes, argue with non-clinicians about my decision, and fax (yes, fax!) my justification to the health plan? Further, patients don’t get their medicine in a timely manner, discharges are often held up in hospitals, and these inefficiencies contribute to driving our healthcare system into bankruptcy.

A 2009 Health Affairs article estimated that prior authorization costs between $23 and $31 billion dollars.  It’s a false barrier that adds little value. Is the insurance benefits manager going to convince me, a board-certified internal medicine physician, that my patient is not going to need insulin detemir? This phony barrier saves the company money if they can withhold some expensive meds from some patients, but it is at the expense of taxpayers and the rest of society. It is akin to a company saving costs by dumping dangerous chemicals in the environment, while people suffer in the process and others are forced to clean it up.

Sadly, I have become somewhat numb to the process and was willing to put up with it to get my patient her medicine.  However, the fact I don’t even have access to this archaic preauthorization process on weekends is beyond unacceptable. I asked the pharmacist how often this happens, and she voiced her frustration, explaining it happens all the time.

My stance is clear: I favor scrapping the idea of prior authorization. But if that’s not going to happen, then companies need to come up with creative solutions to provide 24/7 access (i.e., a temporary three-day override by the pharmacist/physician, an automated system, one on-call person available, hire someone from a different time zone, etc). I (and I’m sure many other doctors) would work closely with the powers that be to help design a reasonably cost-effective solution. It wouldn’t be that hard and wouldn’t cost that much.

And even if it did cause a net loss, guess what? It’s called being accountable. If you want to play in healthcare, you have to understand the system and the critical needs of patients that can’t be left behind.  And if you can’t or don’t want to provide that, then go sell pizza instead.

Vipan Nikore is a hospitalist and president and founder, Urban Future Leaders of the World (uFLOW).

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  • Suzi Q 38

    Frustrating to be sure.
    If my PPO insurance company declines my doctor’s request,
    I call the insurance company for him.
    He and his office does not have time for the insurance company’s

    • querywoman

      You’re a former insurance company drug rep and you know how to word it! Perhaps you and I could write a guide for how to word stuff to get past insurance companies! Then they’ll invent new games.

      • Suzi Q 38

        I just have learned what to say for the most part.
        I try to be nice about it, at first, as I believe that they are just doing their job. I add more pressure with each phone call, by describing my symptoms, etc. I then start getting a little hostile by asking who “made the call.”
        I usually want them to tell me that an NP or physician made the decision to decline my request. Usually, it is a person that works in their office with no medical background other than that job. I find it interesting that a person like that could decide whether or not to approve my MRI.

        I then tell them what I am going to do, which is pay for the test anyway, and then sue them in small claims after the fact. I point out that the price I would get is not the price they would be able to negotiate, so the cost for both of us, whoever wins, will be much higher.

        Eventually, my insurance companies have changed their minds.

        • querywoman

          Great threatening technique! I usually don’t need costly tests, just occasional blood work.
          I only needed the tier cost of my Victoza lowered, and now I know how to do that.
          Dr. Nikore’s problem was substituting a costly insulin for one that wasn’t working for a patient.

  • goonerdoc

    Should it happen? You bet. Will it happen? Not in our lifetimes. Too much money to be made.

  • Martha55

    Getting needed medication 24/7 may seem like a good thing, it probably won’t make any money. Do you think the pharmacy should take a loss to accommodate an irresponsible diabetic patient?

    • Becky

      She had side effects so she stopped taking it.

  • querywoman

    I’m a type 2 and have never heard of insulin detemir. I just researched it.
    I recently ran into a similar problem on a request to get my Medicare D tier expense lowered for my Victoza. I am also on metformin and glimepiride.
    The request was at first rejected because the doctor had not shown that other low cost generics would not be as effective or might be harmful.
    I had been on very high doses of insulin, which started over ten years ago. I either need Victoza or lots of insulin.
    I am responsible and quite a bureaucrat, so I called the Medicare D company myself. I talked to an insurance company pharmacist and found out that my doc needed to write something to the effect that other low cost generics are no longer appropriate due to disease progression.
    He did, and I got my cost lowered.
    But most patients are not going to do this themselves, and that puts you docs in a quandary. It’s obvious here that you probably needed to write specially why insulin glargine no longer appropriate and that you needed to switch her to a med she tolerates better.
    But this insurance Mickey Mousing around (poor Mickey-best term I know of) never stops!

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