Denied. Are you serious? I’m a real doctor.

The experiment took thirty-three minutes and forty-one seconds.   That’s about the time it takes to see a new heart-rhythm patient or implant a defibrillator.

I was just curious. I wanted to dip my toes into the icy waters which so many primary care doctors have already acclimated to.

A denial?  Are they kidding, that medicine fits this patient perfectly. The entirety of cardiology agrees, and so does the FDA, which, isn’t always the case in cardiology–take defibrillators for instance.  (But that’s another topic altogether.)

So I called the long-distance number listed on the denial letter.

…For providers (Argh)…push ‘2’, said the computer message.

For awhile I played along with the automated message, but it wasn’t long before I was jamming the zero button trying to get a human to answer.  Six zeros later came the friendly voice.  Finally.  She was in Pennsylvania; the patient and I were in KY.

Now we are up to 9 minutes.  After a few introductions she asked for the member’s number.  Member?  You mean the patient, right.

…Let me connect you to your “local’ agent.

Back on hold I went.  Ten minutes later another friendly voice answers.

I ask: “What’s up with this denial thing?” While I think: “Hello, do you all know I am a cardiac electrophysiologist.” Though I am certain: they don’t care who I am.

From the friendly local agent, I learn that this particular health plan automatically denies all new drugs.

Snarkily, I ask: “What if the drug cured Cancer?”

Calmly, the voice responds: “It would still be on a moratorium.  Would you like to talk with one of our medical people?”

“You mean your not a medical person?  Sure have them call me.”

I was surprised when a few minutes later a clinical pharmacist called me back. Pradaxa was awaiting approval from their Pharmacy and Therapeutics committee, he said.  They meet in a month or so.  “We have a few local docs on the committee. The primary issue with this drug is that it costs more than warfarin.” Duh!

So there you have it.

Cardiologists agree on Pradaxa’s benefits. So do the epidemiologists and statisticians.  Mathematicians can demonstrate that the upfront costs of the drug are more than made up by its superior efficacy in stroke prevention and reduced bleeding in the brain.   Even the FDA gave the drug a unanimous two-thumbs-up.

But patients on this local KY health plan await the decision of a few local docs and pharmacists.

Double Arrgghh!

When the accountable care organization comes to town, I want to try-out for quarterback, obviously as a walk-on.

JMM

Comments

  1. says

    I understand this must have been frustrating (not to mention time-consuming)…

    I find it interesting to get a birds eye view of how medicine is reimbursed for in the US via your blog; this latest anecdote reminds me of how things sometimes work in the UK. I suspect the health systems of these 2 countries are converging more rapidly than people think.

    The fact of the matter is that health care costs are crippling the western economies, and this kind of denial/ ‘rationing’ will have to be enforced along the line to prevent bankruptcy. Some of this policing has been brought about by doctors ourselves if you were to believe Atul Gawande in this article in the New Yorker
    http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

    It seems that doctors will (quite rightly) have to get used to making decisions not only based on the clinical efficacy of a treatment, but ultimately its cost efficacy and wider public benefit. Its time they introduce health economics into the curriculum at medical school.

    (Having said that, I agree that Pradaxa pays for itself many times over; it’s only a matter of time before your local health insurer calls you back with the green light signal)

  2. says

    I’ve been wondering if Medco and the other drug giants would cover Pradaxa. I’ve noticed that their list of drugs requiring pre-authorizations and special attention are non-generics. Generics don’t seem to require any oversight.
    However, it does seem that they should consider total cost of ownership when prescribing Pradaxa vs Warfarin, rather than just the initial drug price. If they want to run medicine like a business, then they should do so using a well constructed business case.

  3. CardioNP says

    I went thru the hoops the other day to get a patient approved. First attempt was successful, but required a personal phone call to the pharmacist who oversees the approvals for our institution.