Tauseef Ali, MD, on #RespectMyPrescription

Like many gastroenterologists, Tauseef Ali, MD, a gastroenterologist with SSM Health Medical Group in Oklahoma City, Oklahoma, has become increasingly frustrated when dealing with health insurers about prescribing medical therapies for his patients with inflammatory bowel disease (IBD).

Now, he’s turning to the power of social media to get his message out.

Recently, Dr. Ali created the hashtag #respectmyprescription to bring attention to this widespread problem. He took the time to answer some questions from the Gastroenterology Learning Network about denials, appeals, and using social media to effect change.

GLN: What inspired you to create this new hashtag and encourage other gastroenterologists to use it and to report about their problems when dealing with health insurers?

There is growing frustration among patients, physicians, and office staff with medical insurance issues, including prior authorization, denials, and appeal processes. Health insurance plans can be complex and frequently change the medications that are covered and preferred. More recently, we've seen ambiguous, unexplained, nontransparent denials and tortuous appeal processes that have led to frustration among patients and physicians and led to delays in patients receiving appropriate treatment for IBD.

This has also led to critical financial impacts and has even brought trust and relationships between physicians and patients into closer scrutiny. Many patients don't realize where these insurance hurdles are coming from, and why.

With this in mind, I thought of raising these issues and bringing awareness to the community through social media platforms. I want patients, physicians, medical office staff, insurance companies, the pharmaceutical industry, and even more importantly, legislative bodies, to understand what's going on and how it is hurting us all.

GLN: I think you mentioned a case in which a patient had been using a particular drug for several years and then it was denied. How often does this happen, in your experience?

It's happening very frequently. Medical insurance and pharmacy benefits undergo revisions frequently and many drugs go back and forth on their preferred drug lists. Many pharmacy benefit managers have staff making critical decisions based on limited information.

GLN: In this case you also questioned why the insurer didn’t make clear in their denial letter which therapies it WOULD cover for this patient. Is this also a common issue?

Absolutely. There is a dire need for a uniform and standardized policy. I am not against a review of therapy and even of denials, as  factors such as costs must be kept in mind. I wish we didn't have such barriers but in the real world, we have to be aware of such limitations when it comes to access to care.

But one thing that's severely lacking is transparency. The denial process needs to have some set expectations to minimize interference in the care of patients, such as time limits for the review process, denial reasons, alternative choices, and cost to patients.

GLN: Can you tell us about what you’ve experienced when it comes to the appeals process on insurer decisions? 

It ranges from not being connected to the proper office to issues with sending appeal letters; some insurers require that appeals requests be sent by regular mail, which is of course slower. Some insurers send back denial letters after the allowed period for appeals has already lapsed. And the time we have to wait for peer-to-peer review can be lengthy. It all adds up to long delays in treatment for patients, who can suffer relapses, flares, and complications while we wait to get approval for the therapy.

Is there any consistency among insurers in regard to how they approach issuing denials, allowing appeals, conducting peer-to-peer reviews and the like? Or does each do it differently?

There’s no consistency at all—which makes this all the more difficult to manage.

Have you gotten results from using social media like Twitter to draw attention to problems with specific insurers?

Yes. Often societies like the American Gastroenterological Association and the Crohn's & Colitis Foundation have approached us about the issue. Sometimes insurers directly approach us to address the problems.

Have other clinicians taken up this cause on social media? Do you think it can get some traction—and perhaps some results?

Yes. The power of social media can be very effective.

How does all of this affect your patients? Do you frequently find that treatment gets delayed? Do they experience more stress not just due to their illness but also due to delays and concerns about payment for care?

Stress creates risk of flare. Delay in treatment certainly raises the possibility of disease flares. Flares often lead to disease progression, which can make the potential for hospitalization and surgery higher. And of course there is the patient’s suffering that must be considered, too.

What would you most like to see insurers do to alleviate these problems and ensure patients get the right care without delay?

We need implementation of standardized uniform policy across the board. We have recently updated professionals guidelines for using biologics and other newly developed drugs to improve care and the outcomes of IBD patients. These outcomes include reducing hospitalization and surgery, and improving the overall quality of life.

I would like to see insurers, who are among the most important stakeholders, align their goals with those of physicians and patients. One of the very first steps in this regard would be developing a standardized and universal policy based on clinical evidence and recent guidelines. Addressing the broken and poorly structured prior authorization process, developing an expedited review process, and bringing more transparency to the process would be a good start.