by Elizabeth Matsui
The process that begins with a physician prescribing a medication and ends with the patient receiving the medication should be straightforward, but it is not, especially for vulnerable populations who may lack the resources and/or skills to navigate all of the barriers that frequently pop up along the path from prescribing to receiving. Below I discuss the barriers our team has encountered in delivering asthma care, but these same barriers exist for other health conditions.
Our group is currently conducting a study that includes implementation of national guidelines-based medical care for asthma, so that one process that we’ve had to get right is to prescribe an appropriate dose of medication and get it into the family’s hands. We are working with a population of predominantly low-income children and adolescents with significant asthma and, like all health care providers, have encountered many obstacles. However, there are two recurring themes we’ve encountered as we’ve navigated the challenges of implementing this one seemingly small aspect of asthma care: (1) these barriers, rather than making it more difficult to prescribe inappropriate medication, stand in the way of delivering appropriate and highly effective asthma medication, and (2) the burden of barriers is higher for the very population that should have fewer barriers: low-income children who have significant asthma morbidity.
Here are the barriers we have encountered over and over again:
The child’s insurance coverage is no longer active. Re-enrollment in Maryland’s Medicaid plans used to be automatic, but in the past year, families are required to go online and re-enroll their children. The process is not simple and requires internet access, high literacy, and detailed information that many people may have to search for.
To leave our medical facility with prescribed medication in hand, families would have to wait at least 30 minutes and often closer to an hour after a clinic visit. Thankfully, our terrific pharmacy has agreed to deliver medications to the family’s home, but this option is often not available in other settings. Our team calls the family to confirm the delivery because on occasion the prescription has not been received. When this happens, our team works with the pharmacy to rectify the problem.
We see families every two months to reassess the child’s asthma and adjust medication accordingly, but the pharmacy cannot dispense two months’ worth of medication. Medicaid insurance plans in Maryland will only cover dispensing a one month supply at a time. As a result, towards the end of the first month, our team facilitates the refill and delivery of the 2nd month’s supply.
The need for prior authorizations has increased in the past year alone, and requirements for prior authorization are a moving target. The prior authorization phone calls and paperwork delay receipt of appropriate medication by a week or more. We have had to complete prior authorization paperwork for the following scenarios:
a. The family fills a prescription for asthma medication less than 30 days before the visit. At the visit, the study physician determines that the medication dose needs to be changed. Even though the dose needs to be changed, because the family filled a prescription less than 30 days prior to when the new prescription was written, prior authorization forms and phone calls are needed.
b. The child has a known history of severe asthma, and requires a high (and FDA approved) dose of medication. The high dose of the medication requires prior authorization paperwork and phone calls.
c. The participant is taking, and brings to the visit, a medication that had been previously prescribed without a problem, but this medication now requires a prior authorization because either the insurance plan’s policies have changed in the interim or any prior authorization needed for the original prescription no longer stands.
These barriers are not just an annoyance, but are an impediment to delivering medication that is very effective at reducing emergency department visits and hospitalizations for asthma. In this one setting, we have been able to cobble together a safety net that ensures that this one aspect of care for one health condition is executed for a small number of patients, but we clearly need population-wide systems that remove the barriers to patients receiving standard-of-care medication.