COVID-19 and Payor Strategies for Non-Medical Switching

Adam Friedman, MD, FAAD: The pandemic has certainly amplified some of these hurdles for us. Something I noticed when the hammer dropped in March of last year was that we saw a massive push from payers to fax in requests for prior authorizations. They were really ramping up the nonmedical switching and giving us a very narrow window of time to respond before they went forward. I think they were taking advantage of the fact that they knew a lot of offices were closed, that the world was on fire, so to speak, and that people were out or being furloughed. I distinctly remember my medical assistants telling me about this and that they had never seen such an urgency on the payer side to address these things, and I think it was—granted, this is my own personal opinion; I don’t know for sure, but at least this is how I interpret it—that some were taking advantage of the situation. So that’s 1 problem. Even if that was not the case—because of social distancing, offices closing, and furloughing—even if it was the same old rigmarole, balls are being dropped, things are being missed because people are not there, people are not physically in the office. Calling in there should be limited access, so nonmedical switching and parallel patient hurdles certainly jumped through the roof and became much more efficient. That is not a good thing for the patient or for the practitioner.

In terms of the impact of nonmedical switching and how that translates to overall care, let’s start with having a visit. Initially we were, at least at GW [George Washington University School of Medicine and Health Sciences], predominantly doing telehealth, which can make it difficult in certain clinical scenarios to assess the theory of disease. I’m a huge proponent of telehealth; especially in a pandemic, it keeps people home and safe, and it allows them to get the care they need. Even outside of pandemic, it really overcomes some of the costs I mentioned when it comes to nonmedical switching: going in to see a doctor, having to take off work, getting dependent care, keeping someone at home or even at work. Certainly, if someone is flaring up or they are doing worse and you need to really see them firsthand—maybe some new adverse event is emerging that requires a biopsy, or you need to get blood work done because of it—we are limited, or at least more limited than before. Of course, with severe adverse events, patients need to be seen in the emergency department, which was initially flooded with patients with COVID-19. This is overwhelming the medical system if it is happening, and this puts these patients at risk for infection. Let’s think about who we are talking about here. We are talking about patients with chronic inflammatory diseases who are likely more at risk for poor outcomes when it comes to COVID-19 infections. Think about what is killing people. The virus is part of it, but it’s the inflammatory response, the cytokine storm, that is life-threatening. 

All these diseases I’ve been harping on—psoriasis, hidradenitis suppurativa—just want an excuse to set fire to the inflammatory storm, so to speak. These patients, and we know from some registry data, both inside and outside dermatology, are not controlled on systemic agents like biologics. They actually have the worst outcomes when it comes to COVID-19. Nonmedical switching could actually predispose a patient to worse outcomes if they were to get COVID-19, especially if their medication is not working. My opinion based on the data available to us is that in this current climate it is becoming harder to combat, but it also comes with even more baggage, given the new world we live in.

Nonmedical switching is just 1 of many ways payers get in the way of us doing what we do best and what we love to do, which is care for our patients. Those not involved in the care of our patients should not be making the be-all and end-all decisions regarding how these patients—most important our patients—are being managed. We could be part of the solution and not part of the problem. 

Passive observance makes you guilty of being part of the problem, so what can you do? Get involved with the American Academy of Dermatology (AAD). Get involved with the Alliance for Patient Access. Get involved with your local Dermatology Societies. There are so many ways you can be an advocate for your patients. You could be an advocate for your poor but absolutely incredible staff who work tirelessly to make sure your patients are getting cared for. You could also be an advocate for your colleagues, who are banging their heads against the wall when they get those letters from insurance companies that are telling them what they should be using for their patients even if it is not FDA approved, even if what they are proposing is a misinterpretation of a AAD Clinical Guideline that was published 10 years ago. We need to band together. Together we are strongest, and we will overcome this in a way that won’t burn us out. Rather, we will be victorious and once again help our patients and do the best job we possibly can.

Transcript Edited for Clarity