Prior Authorization: Optumrx

My colleagues tell me more and more prescriptions require prior authorization (PA) from the pharmacy benefit manager (PBM). My experience obtaining authorization for buprenorphine for a patient who has been using the drug for close to ten years may help illustrate the problems and opportunities. I last addressed the subject in 2009: Prescription Preauthorization: The New Medical Emergency.

Since we expected the last PA to expire in 90 days it took neither myself nor the patient by surprise when the pharmacy faxed me indicating I would have to call the PBM, Optumrx. As usual I asked the patient to sign my agreement indicating whether I should forward a copy of the medical record at no charge or make the call for my nominal prior authorization fee of $50. The patient chose the latter, and after confirming online payment I made the call.

I navigated the usual menus until the robot told me to enter the number "we have on file." This stumped me. Not only do I not know whether Optum wants my number or the patient's, but surely Optum knows better than I what numbers they keep in their files. Time to start hitting "0" on the keypad. This roused a human, and we got started.

We quickly established the identity of myself and the patient and the details of the prescription, all of which information I had already transmitted to the pharmacy. Then the representative asked for my fax number. Having no desire to receive information from this company via fax or any other medium, I refused. After placing me on hold to confirm that Optum can continue to function without my fax number (What if I do not have a fax number?) we proceeded. Next she asked me for a diagnosis and code. I provided the diagnosis but explained that I do not know the code.

Ultimately Optum approved reimbursement for another 90 days after about ten minutes during which I provided no information that I had not already provided to the pharmacy.

The question of whether PA saves health care dollars is beyond the scope of this post. The patient's contract with the payer determines the conditions of reimbursement. Unless the physician has contracted with the payer this remains between the patient and the payer.

• The physician has no responsibility to obtain reimbursement for drugs.
• The physician must provide a copy of the medical record at the patient's request.
• The pharmacy benefit manager should determine whether to authorize reimbursement based on the record without talking to the physician or requiring the physician to complete a form.
• PAs never constitute emergencies. They are only about money.
• PBMs do not need the physician's fax number or tax ID number.

Some physicians attempt to obtain PA during patient encounters. While this allows the patient to know what transpires, in my opinion a physician who claims such an encounter as psychotherapy or medication management risks accusation of fraud. Better that the patient pay for the service directly, regardless of whether they attend.

With eRx and cloud-based electronic medical records (EMR) we have an opportunity to greatly increase the efficiency of PAs. Ideally, patient and physician should grant the PBM read-only access to the record, allowing such determinations without demanding further involvement of the physician. Until EMRs implement such capabilities eRx should alert the physician to the need for PA immediately on placing the order, allowing the physician to proceed immediately to an online form requesting necessary information.

Physicians afraid to say "no" to yet another intrusion on their time by companies happy to exploit us have enabled this monster. Only when the people who purchase insurance must shoulder the cost will the payers realize they must respect physicians' time.

A New Kind of Abandonment

This third in my series of critiques of the Washington State Department of Health Medical Quality Assurance Commission (MQAC) focuses on the February 9, 2012 Stipulated Findings of Fact, Conclusions of Law and Agreed Order concerning physician Ronald Schubert, M.D. (Respondent).

I extracted the following from the complete Order:

"Over an extended time frame between January 2001 and September 2008... Respondent engaged Patient A in personal e-mails, kissing, dating, phone sex, watching X-rated media, and repeated sexual contacts and intercourse. These activities occurred at Respondent's clinical office, at their respective residences, and at other locations."

The Respondent agrees to take an ethics course in addition to other stipulations, including:

"Respondent's practice is restricted to the treatment of adult male patients."

"(a) Respondent will not have social contact with patients... (b) Respondent will see patients only during normal business hours. (c) Respondent will not treat individuals with whom he has had a social relationship... (d) Respondent will not accept gifts from patients. (e) Respondent will not engage in talk of a sexual nature with patients, except as necessary in the treatment of that patient. (f) Respond will not disclose personal information about himself to patientsg... (g) Respondent will I make house calls... (h) Respondent will not communicate with patients via text messaging, instant messaging or e-mail."

In item (h) the board would seem to see a technological solution to the boundary problem here. This naïve tendency to blame text messaging, instant messaging and e-mail raises questions about the extent to which MQAC members may be out of touch themselves with the realities of communication in 2012. Why for example do they implicitly allow the Respondent to continue use telephone to communicate with patients? Do they not realize that text messaging, instant messaging, and e-mail may create permanent records that might allow for tracking of continued boundary violations? According to the Order the respondent and his patient engaged in "phone sex." Does MQAC not appreciate that telephone contact usually does not create a permanent record and arguably allows for considerably more intimacy than do the prohibited textbased modalities? The Board seems blissfully ignorant of videoconferencing (eg, Skype).

I would argue that the Board should promote rather than prohibit use of textbased modalities to communicate with patients, and even consider adding a requirement that the Respondent maintain permanent copies of all such communications.

"Respondent will enter into psychotherapy with a Certified Sex Offender Treatment Provider therapist approved by the Commission or its designee.... Respondent will see the therapist at least once every two weeks for a period of one year. After this one-year period, the therapist shall determine the frequency of Respondent's therapy... therapist shall inform the Commission of Respondents progress... to protect the public... Respondent may terminate therapy only with prior written approval..."

This stipulation raises questions about the Board's understanding of psychotherapy, about the treatment, and about the ethics of providing that treatment. I will not attempt here to exhaustively analyze the entire subject of "treating" sex offenders. I believe this topic has been and probably continues to be discussed exhaustively elsewhere. The language used in this Order betrays a few of the inherent problems however. The Order speaks of "entering into" psychotherapy without specifying the target of treatment. Will the "patient" be deemed cured when he stops sexual involvement with his patients? Treatment usually implies illness, but no diagnosis appears in the order.

I suspect that no treatment will take place, but rather a "certified" professional will accept remuneration for meeting with (or "seeing" as the Order indicates) the Respondent and monitoring his attitudes for the period required while regularly trumping up reports to the Board in the hope of generating more referrals in the future. I believe this charade will accomplish nothing other than to line the pockets of a psychotherapist whose own participation in this endeavor may be unethical on its face by virtue of the inherent role conflict, while the "patient" learns how to present himself to the "therapist.' The duty of the psychotherapist here would appear to be not to the "patient" but to the Board. I believe this so-called psychotherapy differs little from that which would pretend to change one's sexual orientation, a practice which has been prohibited in some jurisdictions. That a medical board would dignify such a practice by requiring it reflects negatively on the Board as well as the therapist.

"Respondent's abandonment of Patient A without referral to another provider after conclusion of their affair..."

Does this unfortunate language suggest that physicians licensed in the state of Washington have an obligation to refer their patients to another provider at the end, rather than the beginning, of a romantic involvement? Maybe Dr. Schubert should have sent a letter giving 30 day notice: "I will only be available for sexual emergencies." This gaffe strikes me as almost tantamount to Sen. Akin's recent illusion to "legitimate rape." Surely we have a right to expect more from this august body.

Psychiatrists, Light Bulbs, and Bad Medicine

Had it not inspired me to compose a new light-bulb/psychiatrist joke this apparent accusation from David M. Reiss, M.D. on a recent listserv posting that implies I practice "bad medicine" might have offended me: 

"Another (less obvious reason) why the "15 minute med check" that is now the U.S. "standard of practice" is bad medicine. No therapeutic relationship by which to know your patient and communicate effectively on an emotional basis as well as simply providing a few "facts" = increased risks."

Here's the joke:
How many psychiatrists does it take to change a light-bulb? (punchline below)

So a medication management visit that lasts 15 minutes or less is bad medicine? Does that only apply to psychiatrists? What about internists and orthopedic surgeons? There must be a lot of bad medicine out there.

Maybe Dr. Reiss really just wants psychiatrists to provide psychotherapy to every patient on every visit. But what about those non-psychiatrists again? Must the gynecologist do psychotherapy? What about the dermatologist? More bad medicine?

Maybe Dr. Reiss just thinks patients with psychiatric disorders need this extra time. But psychiatric patients need gastroenterologists and ophthalmologists too. Still more bad medicine.

What about knowing your patient? Would Dr. Reiss have us believe that every encounter in which a physician does not "know" the patient constitutes bad medicine? That would probably cover almost every emergency room and urgent care encounter. What's more, I suspect most psychoanalysts would tell us that it takes years to know a patient. Until then, bad medicine? Besides, I would argue that even in intensive long-term psychotherapy the psychotherapist only knows the patient in the context of that artificial setting in the office with no one else around.

Apparently reading my mind, Dr. Reiss jumped the gun, sending me a comment even before I could post this, taking some of the wind out of my sails. He says:

"My argument is not that 15 minute med checks are always "bad medicine", not at all, I believe that it should be a clinical decision how long and how often a pt should come in, not an administrative decision. I would go heavy on 15 minutes being inadequate in the situation that I see advertised all the time - come in as a new doc/locum, take over a case load, but for existing cases, you don't get time to do your own eval or really meet the pt, it's all pre-scheduled at 15 minutes."

Perhaps we agree after all. Even a 30 minute med check may not suffice for a complicated patient, but for a stable patient taking only one medication for a long period of time five minutes may be more than adequate. This is no more true for psychiatric patients than for non-psychiatric patients. Good -- and efficient -- medical practice requires that the physician know which questions to ask in a minimal amount of time. We cannot afford the luxury of truly knowing our patients. Forcing every patient to undergo a 50 minute psychotherapy session whether they need it or want it or not would also constitute bad medicine in my book.

In his "comment" Dr. Reiss addresses two other important problems. He mentions the practice of a new physician jumping in with short follow up visits having not performed a full evaluation. I share his concern. However, one might not be able to accommodate such a thorough evaluation in situations like locums or when covering for another physician at home. As for the prescheduled 15 minutes slot, one can only hope that a no-show or other shorter than scheduled encounter might compensate for a patient who requires extra time. I might add that the old practice of scheduling one patient per hour usually results in less such flexibility of scheduling.

Punchline:
Only one, but the psychiatrist has to know the lightbulb.

Safely send your patients to the Big Easy!

I have it officially from the Louisiana medical board that physicians can talk to established patients traveling in LA by phone or Skype, and even charge them for it without the State of LA charging you with practicing without a license, provided you have a current relationship with the patient in the state in which you are licensed and the patient resides.

Every state should adopt this or similar policy. Enjoy those beignets.

Mississippi: Docs contacting their patients traveling there take a risk

I inquired of the MS medical board as to policy regarding tele contact with patients traveling there from their physician in their home state who is not licensed in MS:

Email from Frances Carrillo at the Mississippi medical Board, responding to my inquiry: “I will forward to the Board attorney on Monday. You have not received a response by the end of next week send me an email.” No attorney contacted me, and Ms. Carrillo did not respond to a follow up email. When I called the board the receptionist would only send me to Ms. Carrillo’s voice mail. It appears that out of state physicians contacting their patients traveling in Mississippi do so at their own risk.

QR Codes for Patient Education Material

There's something archaic about paper "handouts" for educating patients about disorders, drugs and other treatments. Emailing a Web URL is too much trouble, but so many patients have smart phones now I plan to try QR codes. I'll display this page on my tablet PC and ask patients to scan the appropriate codes. I can add more as needed. Other candidates: The Big Book online, doctors and psychotherapists to whom I frequently refer, advocacy and support organizations, etc.

I generated codes at http://www.qrstuff.com/ and created the document in Google docs. Printed to .pdf with CutePDF. (All free.)

Prozac Never Sleeps

Despite all the bad rap heaped on psychopharmacotherapy (psych meds) lately, neither does any other drug. If it's in your brain, it's doin' it's thain. Not so psychotherapists. They (alright, we) do occasionally fall asleep on the job.

Patients: What do you do when your psychotherapist nods off in the middle of a session? How do you feel about that, and do you ever feel safe telling the psychotherapist how you feel about it? Does she ask? Do you start talking louder in the hope it will wake her up? Give her a little nudge? Walk out of the session? Do you blame yourself: "I must be boring her." Does she blame you: "You must be angry." Does she apologize? Do you ever see the eyelids start to droop and do something to try to increase sleep latency? How would you want your psychotherapist to handle the situation when she awakens?

Psychotherapists: Be honest. How often have you nodded off mid-session? What do you do when you feel it coming on? What would you want your patient to do or say? What have your patients done or said? Do you blame the patient or yourself? Do you apologize? Do you educate the patient in advance or wait for it to happen? Sleep latency supposedly reaches a minimum in early afternoon. Do you have any strategies for staying awake then? Ever pinched yourself? Ever refund the patient's fee? How much of a session can you sleep through and still claim reimbursement from a payer?

One of my favorite supervisors for group psychotherapy, a rather brilliant psychologist, used a novel approach. When he sensed the group avoiding significant material he would gradually slouch in his chair. If he did eventually fall asleep, and awaken before the end of the session, he would, he claimed, share his dreams therapeutically with the group.