The insulin Gary Spinner prescribed was making his diabetic patient itch, so Spinner switched her to another type of insulin. But the next time the woman, a 62-year-old factory worker, came to see him, Spinner learned she’d run out of insulin after being told at the pharmacy that her insurance wouldn’t pay for it. She went without, and landed in the emergency room.
The woman was covered through the state’s Medicaid program, but Spinner said the problem wasn’t the state’s coverage policy. Instead, it was the result of a potentially easy-to-fix communications glitch that has kept patients from getting the medication they need, said Spinner, a physician assistant at Southwest Community Health Center in Bridgeport.
More than 5,000 people in the HUSKY program for low-income children and their parents had similar problems filling prescriptions during a 10-month period in 2008 and 2009.
Medicaid, like most insurance plans, has a list of drugs it regularly covers. If a health care provider prescribes a drug not on the list, he or she must submit documentation about why it’s necessary before the plan will cover it. Because health plans have different lists of routinely covered drugs, prescribers don’t always know when they need to get approval for a prescription. And often, Spinner and other health care providers say, they don’t learn about it when a patient is told the prescription isn’t covered.
“The providers are in the dark,” Spinner said, adding that it either falls to pharmacists to notify the prescriber, or the patient, who might not know why the drug isn’t covered.
Spinner and others, including the National Alliance on Mental Illness, Connecticut, want to move the responsibility for notifying prescribers to the state Department of Social Services or to Community Health Network, which administers the state’s Medicaid program. They’ve suggested having one of those entities send a notice to both the prescriber and the patient, explaining why the drug wasn’t covered and what needs to happen to get the prescription filled.
DSS plans to survey medical providers and pharmacists “to help determine the extent to which this may be a problem,” department spokesman David Dearborn said. He said the department doesn’t get many complaints about the process.
Medicaid allows patients who try to fill a prescription without prior authorization to get a one-time, 14-day supply of the medication so they don’t go without.
If the prescriber doesn’t get authorization or order an alternative by the time the 14-day supply runs out, the patient won’t be able to get more.
That happened 5,142 times in a 10-month period in 2008 and 2009 to HUSKY clients, according to a report by Medicaid claims processor Hewlett Packard. That represented nearly one in every five clients who initially tried to get a prescription filled without the required prior authorization.
‘A revolving door’
Since 2010, when Medicaid began requiring prior authorization for certain mental health drugs, DSS has tracked cases in which patients try to fill those prescriptions without prior authorization. Whenever a Medicaid client gets a temporary, 14-day supply of a mental health medication, the department’s pharmacy unit gets an automatic notice from the claims processor, and staff follows up with the prescriber.
When the process began, the pharmacy unit got about 200 referrals a day, Dearborn said. It now averages about 50 per day. He said thousands of mental health drugs are dispensed to Medicaid clients daily.
“Put another way, [prior authorization] is being obtained smoothly, if needed, in the thousands of prescriptions, except in about 50 cases a day (and the staff follow up on those cases),” he said. “To our specialists, the numbers indicate the process is working and the prescribers are getting used to what is available” and what does and doesn’t require prior authorization.
But some health care providers say clients are falling through the cracks.
Dr. Pieter Joost van Wattum, a child psychiatrist and medical director at the Clifford Beers Guidance Clinic in New Haven and the Children’s Center in Hamden, told legislators last month that in recent weeks, he had gotten several faxes from pharmacies and calls from patients about problems getting their prescriptions filled because they had already gotten a 14-day supply. These weren’t first-time prescriptions, but drugs that appeared to be newly subject to prior authorization without his knowledge, he said.
In those cases, van Wattum said he hadn’t heard from DSS.
Having DSS send notices to providers and clients would represent a basic consumer protection that “will substantially reduce the alarming number of cases in which no follow up is conducted, resulting in total denials of access to needed medications at the pharmacy,” van Wattum said in written testimony.
Pharmacists aren’t always in a position to reach prescribers in a timely manner, particularly when patients try to fill prescriptions at night or on weekends, he said. And he noted that Medicaid clients are particularly vulnerable because they don’t have the resources to pay for the medication out-of-pocket to avoid running out.
“This is not a hard problem to fix, and it’s not a hugely resource-requiring issue to fix,” Spinner said. “But it’s broken and it needs to be fixed.”
Elizabeth Rodriguez, branch director at a visiting nurse organization that serves people with mental illnesses, said it’s also important to notify the clients about what steps they should take, in case the paperwork doesn’t reach the prescriber.
“What do you think will happen with these patients? They end up in emergency rooms,” she said. “It’s kind of a revolving door.”
Pharmacists filling in
Pharmacists say that they typically fax information on the need for prior authorization to prescribers — a responsibility they’ve taken on by default.
“Many things in the insurance world have fallen onto the shoulders of the pharmacist to do,” said Margherita R. Giuliano, executive vice president of the Connecticut Pharmacists Association. “We don’t get paid additional fees for this.”
Generally, pharmacists don’t know if the prescriber follows up, or if the drug gets approved, unless the patient returns to the pharmacy. But Giuliano said she doesn’t think patients are going without medication.
Jean Keating, a pharmacist at Granby Pharmacy, said it’s ultimately the patient’s responsibility to ensure that their prescriptions have the right approval, but she said pharmacists typically notify doctors when they need to get prior authorization.
“We’re kind of the middlemen,” she said. “We do a lot of things that aren’t technically our job as pharmacists. If we leave it in the hands of the patients, they don’t know what information to give the doctor.”
Giuliano questioned whether putting DSS or an insurance company in charge of notifying the prescriber would make a difference if the payer, like pharmacists, simply faxes notifications to prescribers.
Still, she and Keating said they wouldn’t object to having the responsibility for notification taken out of pharmacists’ hands.
Commercial insurers also tend to rely on pharmacists to notify patients, or on prescribers to know what drugs need prior approval.
Dr. Ed Pezalla, national medical director for pharmacy policy and strategy at Aetna, said there are electronic tools available for prescribers to use to check the drug they’re ordering against the list of drugs authorized by each health plan. They can be used in conjunction with electronic health records, or separately.
Similarly, Giuliano said the growth of electronic prescribing could help avoid glitches, allowing physicians to get notified electronically as soon as they write a prescription that requires authorization. “Hopefully the process is going to be streamlined as we move towards e-prescribing,” she said.