For the past month we have been working with one our psychiatrists who is treating a mutual patient of ours. This patient has an intellectual disability, lives in a group home, and has significant history of depression with anxiety and attention deficit hyperactivity disorder (ADHD). One of his mediations that he has been taking for over five years is guanfacine. As we have tried to fill this medication for him, the PBM has rejected the claim because the PBM wants him to try a first line agent for hypertension. Herein lies the problem. The psychiatrist’s office has sent in different prior authorizations (PA) informing the PBM the reason the patient is taking guanfacine. Here, the guanfacine is for the treatment of ADHD, and not treatment of hypertension. Each time the PA has been denied, and each time the PBM directs the psychiatrist to use a first line antihypertensive, such has amlodipine, atenolol, or benazapril. What makes this even more frustrating is the fact that this patient also has hypertension and he is being successfully treated with metoprolol.
So my question is “Who makes these decisions?” First, we have a patient whose ADHD has been stable on a medication—guanfacine, the drug is relatively inexpensive, and it has been proven effective. Secondly, if the PBM is really watching over the patient and their medication profile, then why would they recommend a beta blocker (atenolol) when the patient is already taking a beta blocker (metoprolol). To be honest, this is why providers (prescribers and pharmacists) become frustrated with the system—the PBM is not taking the time to look at the individual case and, in fact, is making recommendations that are harmful to the patient.
The patient is frustrated, the psychiatrist is frustrated, and we are frustrated. We will not withhold treatment for this patient, but we have to trudge through the murk and mire of the system set up by the PBM who “supposedly” hires clinical pharmacists to monitor these situations and make clinical decisions. I am not so sure this is the case and, if so, the clinical pharmacist fell asleep at the wheel with this patient. So we become the one who is left “holding the bill”. The system takes up valuable time from both the prescriber’s office and the pharmacy which is time that is taken away caring for other patients.
It is time for a system overhaul. The current system is broken, does not optimize patient care, and penalizes the providers, in the trenches, who are actually caring for the patients. In fact, the relationship between the PBMs and providers has become antagonistic. If we use the current case as our example, what else can we provide to the PBM with regard to the patient’s clinical record to receive an appropriate clinical decision? As a health care provider, I am liable for the decisions that I make regarding my patients and their drug therapies. I take responsibility for the decisions that I do make, which means that I assume the risk as well. PBMs should also be liable for their decisions, because, as this case example demonstrates, their clinical carelessness can have negative consequences for the patient.
As our health care system embraces quality performance, and providers are being held to certain standards of care. Third party administrators (TPAs) such as PBMs should also be held to the same standards. This requires better systems, improving the communication between providers and PBMs. A reasonable start might simply be provider access to a live person—preferably someone who is clinically trained, and a reduction in the length of time for decisions regarding medication coverage to be made. We need to remember the adage, “Its all about the Patient” as we look for ways to improve the system. Right now it seems to be anything but the patient!