From the pharmaceutical manufacturing facility to a patient’s body, an oral or parenteral medication takes a long and surprisingly circuitous route. Most physicians are unaware of the complexity of the process or how deeply regulated it is.
Change Is On The Way
Manufacturers, wholesalers, retail pharmacies, pharmacy benefit managers, health plan sponsors and finally patients are all cogs in a wheel which has accounted for a large and important share of total health care value, but which is rolling to a very dramatic new level of double digit annual increases and some dramatic (and occasionally egregious) increases in the cost of legacy drugs. Pharmacy costs can approach a full quarter of medical expense for many commercial health plans. There are many reasons for this and there is good reason to assign accountability to some of the players. As Howard Brody, MD, PhD has said: “Unfortunately, the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained.” This has implications for all of us.
Taking Steps Toward Simpler Solutions
UHA is advancing administrative simplification to have as few prior authorized services as possible, to reimburse physicians and other providers fairly and quickly, and to provide real value to our members. It is a sad reality that a few providers do order tests, drugs and other interventions with insufficient knowledge of their utility and that the problems inherent in this practice have been articulated by many skilled writers, including Atul Gawande, MD in his essay “Overkill.” Suffice it to say that the problem exists and that broadly applied “solutions” often trap skilled physicians in tedious paperwork and processes which are aimed at outliers.
A New Partnership to Better Serve our Members and Providers
Armed with all of this knowledge, UHA has come to the conclusion it must change pharmacy benefit managers. As of June 1, 2016 we will be associated with Express Scripts. With this partnership, we have worked assiduously to serve both our members’ needs and improve the efficiency of our participating providers by offering an online prior authorization (PA) process through Express Scripts’ proprietary ExpressPAth web-based solution. Our providers will now have access 24/7 to real-time responses to their prior authorization requests via the online portal and may also submit their PAs telephonically, round the clock. There may be some growing pains, but we hope that we can work with our providers so these inconveniences will be few and largely invisible.
Dr. Glenn Ishikawa and I are available to assist you when, and if, clinical problems arise. It is our belief that there will be a material improvement in the services offered including turnaround times, the number and type of prior authorization, and in value to our members. UHA genuinely appreciates what you do for our members and hopes that this change in PBM services will better serve the needs of you and your patients. As always, we welcome your feedback.