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Bureaucracy creates huge burden for HIV clinics
Study details hidden costs to providers
Even with flat-funding, increased patient loads, and a chronic disease that continues to be complex to treat, HIV providers could manage well enough if it weren't for the unfunded burden of bureaucratic paperwork and rules, some say.
"The patient is not at the center of this model," says James L. Raper, DSN, director of the 1917 HIV Clinic at the University of Alabama - Birmingham. Raper also is an associate professor of medicine and nursing at UAB.
"What's at the center of this model is money and profit," Raper says. "And patients don't understand that somebody has to work late at night extra hours to get this all done for them."
A main culprit is Medicare part D's prior authorization process (PAP) which is applied to any situation in which a physician prescribes a medication that the part D intermediary does not have on its formulary. These formularies are determined often by which pharmaceutical company is willing to offer the best contracting cost to the intermediary, not by which medication is best for a particular patient population.
The concept behind the PAPs is to make it so uncomfortable for providers to select medications outside the formulary that they'll choose the drug option that's cheaper for the drug provider, says James Henry Willig, MD, a clinic physician and an assistant professor in the department of medicine and infectious diseases at UAB.
"The process is cost-shifting, not cost-containing," he says.
For HIV clinicians, it seems each new program for patients has a cost that clinicians, patients, or both have to pay.
"Right after Medicare part D was implemented, we saw all these patients coming back to the clinic, unable to get their prescriptions filled," Raper says. "They'd take their prescription to the pharmacy, and the pharmacists would say it wouldn't go through."
This experience spurred Raper and co-investigators to study this phenomenon to see how much extra time clinic employees were devoting to getting medication for patients.1
"I was staying at work until 7:30 or 8 p.m. every day, trying to get all of this work done," Raper notes.
The payer prior authorization requirements were not systematic. Each company had its own forms.
"Many of the forms were not immediately available," Raper says. "You'd have to call to get the forms, and they'd fax them to you, so it was a multi-step process."
Sometimes, Raper has to track down the forms on the Internet, searching through page after page to find the right document.
Then he has to complete the form and find the patient's physician to have it signed, he adds.
"It is mind-boggling," Raper says.
Helping patients find meds
HIV clinics, like the one at UAB, had to devote some staff time to helping patients find medication prior to Medicare part D. Uninsured patients who did not qualify for Medicaid or couldn't receive antiretroviral drugs through the AIDS Drug Assistance Program (ADAP) often were helped by a process called medication acquisition through the pharmaceutical assistance program (PAP), Raper explains.
"Pharmaceutical companies won't deal with patients, so medical providers have to incur the cost of obtaining drugs for them through PAPs," he adds.
The UAB clinic has staff social workers who handled documentation and phone calls required by the PAP.
Then when Medicare part D was passed, some of the PAP patients could receive drugs through Medicare, which was a tremendously good thing for the patients, Raper says.
"Unfortunately, the skill set for the people who were completing the PAP applications is not the same skill set as for people who have to complete prior authorization forms," he adds.
So the clinic's director and physicians had to assume the new time burden.
"What the prior authorization requirement did was diminish one type of workload, one type of function and shifted it to create a much higher-level function for a different type of worker," Raper explains.
"Previously it was the social worker or clerical people filling out forms based on a particular request for a specific medication," he says. "And now what happens is when the patient receives a denial, he has to come back to the clinic and say, 'I can't get this medicine, and I need prior authorization.'"
Then the doctor or nurse has to review the patient's medical coverage and see which medicine is on the formulary for that particular insurance provider, and there are 19 Medicare part D providers, Raper says.
"Then you have to find the doctor to see if we can switch to any of these medications, and if that's okay then we can make the switch, and we've only invested 20 minutes of time," Raper says. "But if the physician says, 'No, this really is not what the patient needs to be on,' then you have to start the prior authorization process to show why the patient needs this drug that's not on the formulary."
A dedicated staff member can become efficient at this work, but since there's no reimbursement, it typically must be added on to existing staff's time, Raper notes.
In the UAB clinic's case, the job has been added to Raper's other duties.
"I've been doing this for two years and have become pretty proficient at it," he says. "So it's much more efficient for me to do it then to have three nurses and nurse practitioners in our clinic do it."
When an HIV clinic's nurses already are working 50 hours per week, the boss rolls up his sleeves and works harder, Raper adds.
The number of prior authorizations is increasing with the clinic's increased patient load. In 2008, the clinic had 183 prior authorizations, up from a little over 100 the year before, he says.
"Many of our patients have to stay on the same medicine for an indefinite period of time, so you have to do the same prior authorization over and over again," Raper says.
Sometimes the PAP defies logic, Raper says.
For example, the new ART darunavir (Prezista) is a protease inhibitor introduced last year. It was provided in 300 mg and 600 mg formulation until the pharmaceutical company did some studies and found that a 400 mg formulation was needed, Raper explains.
"So they quit making the 300 mg tablets," he adds. "But none of the providers have the 400 mg tablets on their formularies, so every time a patient now has a prescription for 400 mg, we have to file a prior authorization."
There are other examples of when physicians will insist on a drug that's not on the formulary for medical reasons, and one of these is when no other drug will work for that patient, Willig says.
"When we have a new HIV agent that comes out, and we can use it in highly-experienced patients, that's a situation where we'll be asked to do a prior authorization when this doesn't make sense because there are no other drugs available for treating that patient," Willig explains.
In some cases, physicians are required to choose an anticholesterol or other type of drug that they know will not work in their HIV patients because the company handling Medicare part D has a deal with another pharmaceutical company and saves money by forcing providers to use a less effective medication, Raper says.
"So you have to use the less effective drug, see it fail, and then you can reapply to use the other drug," he adds.
"It delays the optimal therapy for patients," Willig says.