Planning for B

Psychiatrist and patient have discussed several alternatives for a new medication and settled on a favorite, then comes the dreaded demand for prior authorization for reimbursement. The psychiatrist provides the required information, but the payer denies, and the patient refuses to pay. What now? An alternative prescription means another discussion of dosing and titration as well as risks and benefits. If a telephone or video conference does not suffice, the patient must schedule another office visit with consequent delay in initiating treatment. Maybe psychotherapy or rTMS represents the next recommended alternative.

This scenario plays out for diagnostic tests and other kinds of treatments across medicine. How can we better respond, or even anticipate and prepare?

Ideally in the prescription scenario above psychiatrist and patient might access a formulary with information about reimbursement that can guide the choice of drug, but regardless, discussion of Plan B might help avoid delay in starting treatment. The psychiatrist could review the most likely and most serious adverse effects of one or more fall back drugs before the patient presents the prescription to the pharmacy.

Sometimes a patient decides against the planned treatment based on non-financial considerations. A patient recently contacted me after I ordered lamotrigine and expressed discomfort with the risk of fatal skin rash associated with the drug. Agreement on another plan will require another office visit.

Best practice may just demand that we (almost) always anticipate and prepare.

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