Lots has been written about the wasteful administrivia that primary care physicians have to engage in to provide our basic services, like getting a patient the appropriate medication. Recent studies published in Health Affairs have estimated annual costs to individual doctors in large groups of over $85,000.00 a year, just for the overhead of getting authorizations and dealing with insurance companies for billing and case management. Primary care physicians, especially solo or in small groups are hit even harder. But the real problem is that our system hurts patients and sours doctors by forcing them to do unpleasant, wasteful tasks that do not benefit the patient or the health care system in any way, while raising the costs to the system as a whole. The biggest cost is that primary care physicians get so disgusted that they retire early, or move into other kinds of practice, such as cosmetic medicine or urgent care, where they do not have to deal with actual long-term patient management.
Let me give you an example of how I spent the last hour today:
I have a patient (let’s call him “Joe”) I have been treating for the last 15 years with a problem for which the medications we had tried would lose their effectiveness over a period of months to years. The specialist who treats his daughter for the same problem, recommended that he try a new medication, which was working for his daughter. Joe asked me to prescribe it, and I researched it and agreed it was reasonable to try, so I wrote him a prescription.
A week later, Joe’s pharmacy faxed me a note indicating that I needed to go through a preauthorization process to get the medication authorized. They sent me the only phone number they had for this, which was for the patient’s pharmacy benefit manager, so I called it. The phone tree did not have a choice for “doctors who want to preauthorize something,” so I chose one of the selection choices, waited on hold for 5 minutes, and got a pleasant woman who needed to verify my name and DEA number, Joe’s name, date of birth, SSN, and employer. The nice woman put me on hold for a couple more minutes to look things up, and then told me that I needed to be transferred to the preauthorization department (which I told them at the beginning). She kindly transferred me there.
After 5 more minutes on hold, I was connected with another pleasant woman who once again had me provide my name and DEA number, Joe’s name, date of birth, SSN, and (after a couple of more minutes of waiting) I was told that I need to get this authorized through the insurance plan. She kindly transferred me there.
After being transferred again, and after about 5 more minutes on hold, another pleasant and helpful woman asked me to provide my name and DEA number, as well as my Tax ID Number and the name of my practice, Joe’s name, date of birth, and Social Security Number. After checking for a minute or two, she told me that that this actually has to go to customer service. She kindly transferred me there.
Customer Service was quite busy, so it was 7 minutes on hold this time. A pleasant woman answered the phone, and after I had provided my name, practice name, Tax ID number, DEA number, Joe’s name, date of birth, SSN, as well as Joe’s age and diagnosis, and I am told that his employer will not allow them to dispense medications “in that class” without a written letter of medical necessity. She couldn’t explain why he had tried six other drugs “in that class” without needing to get a preauthorization, nor could she explain why his daughter, who has the same diagnosis, was provided this medication without preauthorization from her company. She did give me number to fax a letter to, and told me I needed to document his diagnosis, all of the medications he had tried, the outcomes of each of them, and why I felt it was necessary that he try this new medication.
Everyone on the phone was nice, and all of these conversations were recorded to prove it, but the bottom line is that it took me 28 minutes on the phone to find out that I actually needed to write a letter requesting coverage, and to find out where I had to fax the letter.
It would typically take me about 20 minutes to write a letter that documents a patient’s history regarding a given diagnosis, all of the medications that had been tried and failed, and why the patient should try a new medication, but I had some system problems with my EMR, and I had to use Microsoft Word to create a letter on my letterhead, and it gave me some trouble with the formatting, so it actually took 37 minutes to do the letter and to get it faxed out.
So, this time, it took a full 60 minutes rather than the typical 40+ minutes most of these preauthorizations take.
Most primary care offices have overhead cost of $2.00 to $3.00 per minute of doctor’s time, so the average cost of to the doctor for each preauthorization is $80.00 to $120.00 if the doctor does it all, or $55.00 to $75.00 if the doctor has staff do the phone work and just does the letter him or herself. There is no way to make the insurance company or the pharmacy benefit manager pay for this, so the doctor pays for it. In order to generate enough money to cover the cost of providing the service, a physician has to see an additional couple of patients to cover each one of these authorizations.
Most primary care doctors have pretty full schedules, so the only way they can see the additional patients they need to see to cover the expense of providing these services, is to reduce the time they allow for each visit. This results in less time available for seeing each individual patient, and the end result is that the quality and expense of care goes up because doctor often ends up ordering expensive tests (like MRIs and CT scans) that would have been unnecessary if he or she had adequate time to spend with each patient to make a diagnosis with a careful history and physical exam.
Fortunately, in my practice, which has a very low overhead (running out of the basement of my house) and which has no employees (except for my wife who volunteers to greet patients), there is no out-of-pocket cost to me for doing this. It just took an hour of my time that I could have spent mowing the lawn or catching up on charts. But, if I were able to spend the time every week I have to devote to these kinds of senseless medication authorizations (at least 3 – 4 hours a week in my half-time practice) actually seeing patients rather than getting authorizations, I would be able to provide quality primary care for couple of hundred additional patients. As it is, my “half-time” practice is actually full time and more, since medication preauthorizations are just one of many wasteful administrative tasks I have to do to make sure that my patients get even minimally adequate care. And, I turn down several new patients every week simply because there is not enough time in the day to do all of the administrative tasks I am forced to do by our dysfunctional non-system of medical care, let alone to take on new patients, too.
For medical students, when they are making a choice of what specialty they will go into, seeing primary care physicians being burned out doing pointless administrative tasks that take up half of their working hours and that do not benefit anyone, is a major turn-off for a primary care career. This is a much more important factor, according to my medical student friends, than the much lower salaries primary care doctors earn than physicians in other specialties. In order to develop the strong and efficient primary care workforce that our country needs, we need to make primary care medicine fun and less frustrating than it is now, so that someone will want to do it.
Donald T. Stewart, MD