{"id":10377,"date":"2022-03-07T11:27:14","date_gmt":"2022-03-07T16:27:14","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10377"},"modified":"2022-03-07T11:30:10","modified_gmt":"2022-03-07T16:30:10","slug":"how-to-induce-rage-in-a-doctor","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/how-to-induce-rage-in-a-doctor\/2022\/03\/07\/","title":{"rendered":"How to Induce Rage in a Doctor"},"content":{"rendered":"
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Advertisement for Hunt’s Remedy, which cured all diseases but did not require a prior authorization.<\/em><\/p><\/div>\n

If you’re wondering how to make a doctor angry — really, really angry — read on. Because asking us to justify treatment decisions to insurance companies and their pharmacy benefit managers must rank right up there with the greatest tortures of practicing medicine in this country.<\/p>\n

Mind you, this isn’t just about my patient, or about me — such infuriating events take place innumerable times in countless offices, hospitals, and clinics around the country every day, wasting everyone’s valuable time with no evidence whatsoever that they improve the quality of care.<\/p>\n

Such struggles are an inevitable part of\u00a0a healthcare system that values profits over people.<\/a> The debates require a veritable army of staff on both sides to navigate what should often be very straightforward treatment issues.<\/p>\n

Here’s a timeline of what happened. It’s Part 2 of the case presented a couple of weeks ago<\/a>, which appeared with the patient’s permission (certain details changed).<\/p>\n

February 6:<\/strong> \u00a0Patient notifies me he needs a corticosteroid injection for back pain, which is contraindicated with his current HIV therapy due to a potentially serious drug interaction. We set up a video visit to discuss alternative HIV treatment options.<\/p>\n

February 7:<\/strong> \u00a0Televisit. I explain some treatment options, which I outline as bictegravir\/TAF\/FTC, dolutegravir\/3TC, or doravirine plus TAF\/FTC. He opts for the doravirine option based on side effects from previous treatments. Prescription sent to pharmacy.<\/p>\n

I mention to him that doravirine sometimes requires a prior authorization. I also tell him that with his employer-provided insurance, it most likely will be fine. After all, the guy has a high-powered job in a very well known organization. He must have good coverage.<\/p>\n

Furthermore, while HIV treatment remains quite expensive<\/a>, none of the alternatives I’ve offered costs significantly more than what he’s currently receiving, and some cost less — at least based on the prices available to us.<\/p>\n

Ha. Not so fast.<\/p>\n

February 10:<\/strong> Message from patient that his pharmacy told him doravirine wasn’t covered. Needs a prior authorization.<\/p>\n

I ask our pharmacy team, which consists of pharmacists and pharmacy techs hired for this express purpose, to help with it. They send it in, along with my office note from the televisit which justifies the reason for the treatment change.<\/p>\n

February 14:<\/strong> I hear from the pharmacy team — prior authorization has been denied. Oh, and there’s this message:<\/p>\n

Alternative Requested:\u00a0 PIFELTRO [doravirine] is NON-FORMULARY. MUST USE EFAVIRENZ, NEVIRAPINE, EDURANT. Call xxx-xxx-xxxx.<\/p><\/blockquote>\n

Well, this is a joyful Valentine’s Day present. They obviously don’t know his medical history, or much about HIV treatment. Why can I make this assumption?<\/p>\n