Author + information
- Robert D Gibson, PharmDa
I am writing in response to the editorial in the March issue of the Journal of the American College of Cardiology (JACC)(1) concerning the administrative challenges associated with insurance coverage for prescription drugs which struck a resonant chord. As President of the American Pharmaceutical Association (APhA), the national professional society of pharmacists, I can assure you that my profession is equally as frustrated with the inefficiencies and unproductive hassles associated with many managed care programs today. A recent study by Arthur Anderson shows that over 20% of a pharmacist’s time is spent directly on activities related to insurance issues (2). These include determining eligibility status, resolving formulary and coverage issues and solving billing problems.
Because community pharmacies provide “point-of-service” claims processing for prescription medications, pharmacists are often placed in a difficult and undesirable position of mediating insurance issues so that the patient can receive the prescribed medication. Often, pharmacists must contact physicians for authorization to change a patient’s medication to be compliant with the plan formulary or to receive a prior authorization. These coverage decisions are outside of the control of the pharmacist.
As you describe in your article, contacting the “help-desk” at an insurance company is usually less-than-helpful. These call centers are often understaffed with employees that are poorly trained and unempowered to assist providers by authorizing clinical overrides. This causes significant delays and often forces providers to make decisions based on plan parameters as opposed to patient parameters.
I fully support the principles that you have outlined to “restore rationality” to this process, but I suggest the addition of one point—physicians and pharmacists must work together to ensure changes in the design of health benefits that reduce the administrative burdens for all providers and, more importantly, facilitate the efficient delivery of health care services to our patients.
As frustrating as these administrative barriers are to providers, they are often even more frustrating and confusing for our patients. Physicians and pharmacists must work toward building a medication delivery system where “care” is more important than “coverage.”
As you know, there are many other health care delivery issues we could discuss but I am, as usual, tied up on the phone trying to obtain authorization for Mrs. Brown’s heart medication which is, not surprisingly, unavailable on her health care plan’s formulary.
- American College of Cardiology