John Tesser, MD: Jen, you touched on this a bit. How do we handle patients who may be less compliant? How do we oversee their medications? Do we hold off prescribing them? Give me a sense of your approach to this.

Jennifer Simpson, DNP: Having those conversations with the patient and building that relationship with them is definitely helpful for compliance. You’re going to understand where the patient is coming from, and they’re going to understand where you’re coming from. Building that relationship is a big part of this. Having those conversations with them—if they’re having compliance issues, why are they having compliance issues? Is it because they have a needle phobia and they don’t want to take that injection they’ve been prescribed? Are they having issues with their specialty pharmacy? This is probably something you guys have both come in contact with. The patient is like, “I’m not getting my shipments on time,” or “It was delivered in the 100-degree heat in Phoenix [Arizona].”

It’s understanding where the patient is coming from. It’s not always just that they don’t want to do something. There’s often a legitimate reason for it, and from there are things we can mitigate with that. Maybe it’s something where they do come in for an infusion because we have better track of keeping them in the office and then they don’t have to worry about their specialty pharmacy or shipments coming to them. It’s a matter of understanding that situation. If the patient is having compliance issues, what is it? Are they having transportation issues and trouble getting to the office? Do we have the option to do telemedicine? Is it an insurance issue, getting the referrals on time? Working with Medicaid, that’s something I come across quite a bit—where the patient needed a new referral and couldn’t get into their primary care on time.

Sometimes we have to give them a little grace and understand that they’re dealing with things outside their control. Setting those expectations for them—what we expect from them, what do they expect of us, trying to understand where that compliance issue may be coming from, and trying to adjust accordingly to make it best suited for them. There’s also something to be said as practitioners not allowing our patients to walk all over us. I have some patients who will take advantage and not come in for their blood work. They expect to keep getting refills on medicines and make that understood, so [we have to] set the expectation that you’re not going to get away with not being monitored. That’s a risk for you and a risk for us as prescribers.

John Tesser, MD: Absolutely. It puts us in a box because we don’t want their disease to flare. On the other hand, we have to have a safe context in which we’re prescribing these drugs because the drugs can hurt them also. It can be a very difficult tightrope to walk. There are those patients who don’t tell you they’re not taking their medicine, are they’re not doing well. They’re flaring, and the reason is that they’re not taking their medicine. With some medicines, we have the ability to monitor levels of drugs; with others, not so much. One way to look at it is to see whether they’ve been getting refills on their drugs. That’s not always airtight though because some of my patients are getting refills on a drug that I haven’t filled for months or a year. This is the challenge we have.

Nehad we have another challenge, which is the step edit issue. Give us an overview of that, and tell me how many hairs you’ve lost fighting payers about this.

Nehad Soloman, MD: The front of my hairline used to be a lot fuller. That’s how much hair I’ve lost. Indeed, as much as we say we have all this liberty and all these options, many of the challenges we face and decisions we have to make are governed by third-party payers. You must use drugs X, Y, and Z. Thinking back to what we had previously mentioned about conventional DMARDs [disease-modifying antirheumatic drugs], many of us might be reluctantly using more than we want to because it’s a step edit. The third-party payers say you must use methotrexate or leflunomide. As you mentioned, it may not be appropriate for somebody with predominantly axial disease, so that’s where you step in with your expertise—you make phone calls, you write letters to contest it. For the most part, you get to overturn those decisions but not without a fight. That’s the bigger challenge. With a busy practice where we’re trying to meet the demands of the community, an aging population, how much time do we have to write these letters? We’re constantly trying to find innovative ways to have canned letters that we can refine and that won’t take too much of our time, but we make them specific for those patients so we can get through.

The other challenge is some of the companies have eliminated their prior authorization department or their appeals department so that they don’t want to hear from you. Even if you try to appeal, there’s nobody to appeal to. That’s been a frustrating battle in and of itself. Often I’m going to take the path of least resistance. If they’re telling me I need to use drugs A, B, and C first, I’m going to do it as long as it doesn’t cause harm to the patient and it makes clinical sense.

The challenge with that is if you have a noncompliant patient. If they’re noncompliant, it may accelerate the game plan because you can demonstrate they’re not getting better, mainly because they’re not using the drug. But if you document appropriately and say, “They’ve tried X, Y, and Z, and they’re not doing well. Now I want [this] drug, which is the original drug I wanted, and it’s administered in the office where I have total control.” Then you make progress to some degree. But the challenges with step edits are tumultuous, not to mention the cost burden to practices. Our practice spends something to the tune of half a million dollars a year to employ folks to get prior authorizations and get through the red tape to get this done. We’re not compensated for that, but we do it because it’s what we need to do for our patients. We have to get them these medications.

I often think we’re in the fire zone. If it doesn’t happen, or if there’s a delay, or if the shipment doesn’t arrive, we get the blame even though we’re doing all this work and not getting any benefit but all the criticisms. It’s sad. With any other drug, we’d write a script and give it to the patient or send it electronically, and then they would have to deal with the pharmacy. I wonder why we wouldn’t push that burden onto pharmacies and say, “If I write the electronic prescription to the pharmacy, you need to deal with them to get the prior authorization.”

I’m not sure how we got involved in all this, but some of the other aspects of step edits include providing records. Probably the most frustrating thing is when they tell you, “You must try drugs X, Y, and Z.” You did, but they’ve denied you because they didn’t read your chart. Now you have people who are rubber-stamping denials to protract time, so they buy themselves a quarter or 2 without approving the drug just to save money. There’s great frustration when that happens.

This transcript has been edited for clarity.