A simple health care reform for North Carolina

Published July 28, 2017

[caption id="attachment_22428" align="alignleft" width="150"] Pholo by Daily Reflector[/caption]

by Dr. Tate Holbrook, published in Greenville Daily Reflector, July 27, 2017.

With the health care reform debate raging in the halls of Congress, it can seem like anything to do with fixing health care is at a standstill. But there are still improvements that health plans here can — and should — be making, regardless of what happens on the federal level.

In my pediatric practice here in Greenville, we are focused on treating children with complex conditions — from prematurity and special needs to attention-deficit/hyperactivity disorder (ADHD). Recently, a health insurer made the decision not to cover the type of ADHD treatment that allows some of my young patients to focus in school.

Why? Because the insurer has now decided to only cover a capsule form of this treatment, not a chewable tablet or liquid format that the patient can swallow or a patch that can be placed on the skin.

If you have a child or remember being one, then you know that a 4-, 5-, or 6-year-old typically cannot swallow a big pill. It’s common sense that if the same health plan has covered the liquid, chewable tablet or patch version during the same policy year, and it’s working for the patient, then they should theoretically be able to remain on this treatment.

But, it’s not that easy.

When I get calls from parents who realize they won’t be able to refill their child’s prescription, I jump into action with the insurance company and fight through the so-called prior authorization process. In fact, our office employs someone whose job is to appeal these types of health plan decisions. But even so, there are pages and pages of appeal forms to complete and submit, and it can take up to two weeks to get approval — even with daily phone calls to the insurer. Meanwhile, the child may go without medication.

The reality is that not every health care provider has the time or the staff to call and email an insurer until an appeal is granted; and that’s what it takes.

So, as we look for ways to reform health care, making the prior authorization process simple and faster would be a great place to start.

Unexpected insurance coverage changes can happen at any time, even in the middle of a policy year, and health care providers should be able to easily appeal those changes if we know that switching medications will be harmful for our patients.

We need standardized electronic forms that can be easily completed. We also need a quicker process. North Carolina Medicaid, for instance, typically reviews standardized electronic forms and issues an approval or denial within 24 hours. Medicaid insurance vendors are also required to justify a change that differs from what has worked for a patient, sometimes for years. There’s no reason why private health plans shouldn’t be able to do the same.

Not only would these common sense prior authorization reforms have a positive impact on young patients like mine who need to continue taking liquid medication, but it would help patients across the state whose physicians need to be able to swiftly and effectively communicate with health insurers.

There’s no doubt that the health care system is complex, but not every potential improvement to health care is complicated. Even as federal health care reform hangs in the balance, prior authorization reform is a good and commonsense way to make health care work better here in North Carolina — right now.

Dr. Tate Holbrook, MD, is a physician at Children’s Health Services. He has been seeing patients in Greenville since 1979.

http://www.reflector.com/Op-Ed/2017/07/27/A-Simple-Health-Care-Reform-for-North-Carolina.html