An ongoing dialogue on HIV/AIDS, infectious diseases,
March 7th, 2022
How to Induce Rage in a Doctor
If you’re wondering how to make a doctor angry — really, really angry — read on. Because asking us to justify treatment decisions to insurance companies and their pharmacy benefit managers must rank right up there with the greatest tortures of practicing medicine in this country.
Mind you, this isn’t just about my patient, or about me — such infuriating events take place innumerable times in countless offices, hospitals, and clinics around the country every day, wasting everyone’s valuable time with no evidence whatsoever that they improve the quality of care.
Such struggles are an inevitable part of a healthcare system that values profits over people. The debates require a veritable army of staff on both sides to navigate what should often be very straightforward treatment issues.
Here’s a timeline of what happened. It’s Part 2 of the case presented a couple of weeks ago, which appeared with the patient’s permission (certain details changed).
February 6: Patient notifies me he needs a corticosteroid injection for back pain, which is contraindicated with his current HIV therapy due to a potentially serious drug interaction. We set up a video visit to discuss alternative HIV treatment options.
February 7: Televisit. I explain some treatment options, which I outline as bictegravir/TAF/FTC, dolutegravir/3TC, or doravirine plus TAF/FTC. He opts for the doravirine option based on side effects from previous treatments. Prescription sent to pharmacy.
I mention to him that doravirine sometimes requires a prior authorization. I also tell him that with his employer-provided insurance, it most likely will be fine. After all, the guy has a high-powered job in a very well known organization. He must have good coverage.
Furthermore, while HIV treatment remains quite expensive, none of the alternatives I’ve offered costs significantly more than what he’s currently receiving, and some cost less — at least based on the prices available to us.
Ha. Not so fast.
February 10: Message from patient that his pharmacy told him doravirine wasn’t covered. Needs a prior authorization.
I ask our pharmacy team, which consists of pharmacists and pharmacy techs hired for this express purpose, to help with it. They send it in, along with my office note from the televisit which justifies the reason for the treatment change.
February 14: I hear from the pharmacy team — prior authorization has been denied. Oh, and there’s this message:
Alternative Requested: PIFELTRO [doravirine] is NON-FORMULARY. MUST USE EFAVIRENZ, NEVIRAPINE, EDURANT. Call xxx-xxx-xxxx.
Well, this is a joyful Valentine’s Day present. They obviously don’t know his medical history, or much about HIV treatment. Why can I make this assumption?
- Efavirenz caused severe side effects years ago — he can’t take that.
- Nevirapine is not recommended in any treatment guidelines anymore, especially in people (like my patient) with high CD4 cell counts, as this increases the risk of severe hypersensitivity — he can’t take that.
- Edurant (rilpivirine) should not be given to people with low stomach acidity since it won’t be fully absorbed — he can’t take that.
I’ve always wondered — what if we followed these directives, and something truly terrible happened? After all, there are people who have died from nevirapine hypersensitivity, either from toxic epidermal necrolysis or fulminant liver failure or both.
Would the insurance company bear any of the blame, or legal risk? Would they care? I know the answer, sadly.
February 15: I call the phone number, which takes me to the pharmacy benefit manager. It’s the Giant-est of the Giants. How do annual revenues of more than 30 billion dollars sound? Pay for plenty of doravirine with that.
Phone tree. Then hold music. A warning about high call volume and long wait times. Then a person. Below a sampling of the dialogue.
Pharmacy Benefit Manager person #1: Hello, you’ve reached Brett. May I have the client’s member number?
Me: I don’t have it. I have his name and date of birth.
PBM person #1: OK, I’ll take that.
[pause while they look up the record]
PBM person #1: It says here the prior approval was denied. Pifeltro is non-formulary. You must use [pauses] EFAVIRENZ, NEVIRAPINE, EDURANT. [Difficulty reading the HIV drugs implies no knowledge of HIV medicine.]
Me: I know that — this is why I’m calling. But he can’t take any of those.
PBM Person #1: Do you want a clinician-to-clinician consultation?
Me: Yes. That’s why I called — this is the number we were given.
PBM Person #1: OK, let me transfer you.
[Hold music. Another warning about high call volumes and long wait times.]
PBM Person #2: Hello, you’ve reached Blake. May I have the client member #?
Me: I just gave that information to the previous person. Didn’t they pass that along to you?
PBM Person #2: Sorry, no.
Me: I have the name and date of birth, not the client #.
[Information given again.]
PBM Person #2: It says here that your prior approval was denied. You must use [pauses] EFAVIRENZ, NEVIRAPINE, EDURANT [more difficulty pronouncing the HIV drugs].
Me: That’s what the last person said to me, and I already know that. My patient can’t take any of these drugs. This is supposed to be a peer-to-peer consultation.
PBM Person #2: They sent you to the wrong number. I can forward.
[Hold music. Long hold.]
PBM Person #3: Hello, this is Bobby. May I have the patient’s name and client #?
Me: I only have the name and date of birth.
[Information given again. Third time, but who’s counting.]
PBM Person #3: I found the record. The Pifeltro was denied.
Me: Yes, Bobby, I know that, this is why I’m calling. Hoping you can help me. I’m an ID/HIV specialist in practice since 1992, and I’ve known this patient since 1996, including his full treatment history. The recommended alternatives are contraindicated — he can’t take any of them.
Me: Hello, do you need any further information?
PBM Person #3: I’m sorry, doctor, but I am not authorized to approve this drug.
Me [more than a little annoyed at this point — in fact here’s a good description of how I looked]: Why then am I speaking with you? This is the phone number I was advised to call. Are you a clinician? Do you have any knowledge of HIV treatment? Do you have access to the notes that were submitted for this claim?
PBM Person #3 [sounds like Bobby is now driving a car while speaking with me]: I’m sorry, Doctor. I am not authorized to approve this drug. If you want to appeal, or the patient wants to appeal, they will need to directly contact his insurance company with an appeal letter.
So why did all this happen? Why did Brett, Blake, and Bobby each fail to help my patient get his prescription covered?
It all starts with the relatively high cost of HIV treatment to begin with — a cost that has increased over 30% since 2012, a rate 3.5 times faster than inflation. Unlike most other industrialized countries, where government payers gather disease experts to review treatment options, then work with the pharmaceutical companies to arrive at a cost, such deliberations here are explicitly blocked and remain controversial.
With antiretroviral therapy so costly, insurance companies enlist the PBMs to negotiate what treatments get covered, what don’t, and how much they’re going to cost. It’s all done behind closed doors, in exchanges that one insider told me are “brutal.” As concisely (and accurately) stated in the opening to this recent perspective, “Prescription drug prices in the United States are opaque.”
The PBMs also sometimes direct where patients can most easily get their prescriptions filled (which may be the same companies, imagine that), and discourage dispensing of less expensive (but not negotiated) products.
If you think this clandestine process is ripe for distortion, obfuscation, and misuse of power, you’d be absolutely right. The lack of transparency means my patient and I have no way of finding out why doravirine isn’t covered — just that it isn’t.
But one thing I can state with 100% confidence — the refusal to cover my patient’s doravirine prescription has nothing whatsoever to do with improving the quality of his care, or following treatment guidelines, or really anything related to his health at all.
It was all about money. And that is sad indeed.
Hey, two more entries for the timeline:
February 25: Received information about the appeal process, and wrote the letter.
March 7: Still waiting …
(Thanks to brilliant colleagues Drs. Aaron Kesselheim and Ben Rome for reviewing this post. And to Dr. Glaukomflecken for making us laugh and cry at the same time.)