Dr. Jose Luis Bautista: Let's help patients receive more timely care

June 4, 2014 

Critical decisions about the health of countless people in Fresno and around the country are increasingly being removed from the hands of their physicians.

Health insurers have inserted themselves into the physician-patient relationship and are interfering with the ability of patients to access the course of treatments that their doctors think best.

In the name of health care cost containment — a vague and oft-repeated mantra — health insurers have put in place a series of bureaucratic hoops that doctors and patients must jump through to gain access to the treatment doctors think best.

These protocols and barriers to access go by many different names — prior- or pre-authorization, step therapy, specialty tiers — but the impact is always the same: Patients can go for days, weeks or months without the medication they need, which can cause their health to deteriorate.

In California, the prior authorization process, for example, is highly complex and lacks transparency. The criteria and processes vary significantly among health plans. Health plans have different pre-authorization, appeal and benefit advisory requirements, and these requirements increase the burden on health care providers, whose staffs are tasked with keeping track of the various requirements and the different methods of communicating the information to insurers.

The approximately 9 million people in the Medi-Cal program, including many of the state's most vulnerable populations, already have very restricted access to medicine under managed care and often cannot get access to the medicines they need.

When patients switch from one health plan to another, as often happens in the state Medi-Cal program, the bureaucratic hassle and delays in treatment are exacerbated.

I treat many Medi-Cal beneficiaries in Fresno who have told me that, after switching plans, they no longer have access to the drugs that are already successfully treating their condition. In some instances the drug is not covered by the new plan, and in others the plan forces patients to go through the prior authorization or step-therapy process, even when the patients have already previously done so.

The problem has become more acute since the enactment of the Affordable Care Act (ACA), which has precipitated an increase in the number of patients switching from one managed care plan to another.

Fortunately, the state of California is considering taking common-sense action that would help.

The Department of Health Care Services has proposed a new statewide Medi-Cal drug formulary for all Medi-Cal beneficiaries that would make any of the drugs on the new formulary available to my patients without access restrictions.

The proposal creates a core drug formulary for Medi-Cal managed care plans and the state would negotiate directly with companies for medicine on this formulary. Health plans would be able to contract with companies for any additional medicine to add to their formulary.

Any product on the formulary would have to be provided to patients by the managed care plans without access restrictions, which would help ensure continuity of care, protect patient access to medication, reduce confusion and limit the onerous burden of bureaucratic insurance hassles.

California policymakers and regulators should support this new proposal and keep the physician-patient relationship at the center of decisions about how to treat patients.


Dr. Jose Luis Bautista is a practicing physician in Fresno.

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