COMMENTARY

The Death of Yarushka Rivera: Prior Authorization Run Amok

Melissa Walton-Shirley, MD

Disclosures

June 19, 2018

In May 2009, Yarushka Rivera suffered a seizure. She was diagnosed with epilepsy and prescribed topiramate (Topamax, Janssen). In August, Rivera turned 19 and her insurer MassHealth began to require a prior authorization for her Topamax prescription. She tried five times to fill the prescription at her Walgreen's pharmacy, unsuccessfully.[1]  The pharmacy stated that the prior authorization form had not been completed by her physician. Her family could not afford the nearly $400 out-of-pocket cost and claim that they contacted the prescribing physician's office seven times, with no response.[2] The pharmacy allegedly kept promising that it would also contact the physician's office but has no record of any communication with the prescriber.

In October 2009, Yarushka Rivera suffered a fatal seizure. She had been without her oral medication for 2 months, having visited the emergency department for a loading dose when her seizures recurred. This tragic and preventable death is a sentinel event for the US healthcare system. Perhaps it will open a window of opportunity to destroy the archaic prior authorization process for its inefficiency, and its devastating effect on patient care, but I fear it will miss its mark.

The Lawsuits

The family sued Walgreen's, the provider, and a mental health facility that had treated Rivera for bipolar disorder. Initially, the court ruled in favor of Walgreen's; then, on appeal, the Massachusetts Supreme Judicial Court ruled this month that a pharmacist has a duty to take reasonable steps to inform both the patient and the physician when a prescription requires prior authorization. The case will eventually be heard in a superior court that will decide whether the pharmacy or the physician's office is liable. The suit against the mental health facility is being litigated separately.

But what about the insurance company? Doesn't it bear most of the liability for mandating a useless rule that impeded the patient's ability to obtain proper treatment?

Why should be there be a prior auth requirement in this case at all?

If a US Food and Drug Administration–approved drug is prescribed for the appropriate indication and the patient has filled that prescription previously, why should there be any interruption in coverage? Shouldn't that point alone be litigated? Why should an insurance company have the legal ability to use the arbitrary age of 19 to build in an obstacle to access for a lifesaving medication? The court documents note that "the paperwork was two pages long and would take less than 10 minutes to fill out." Does the justice system really understand the prior authorization process? Unmentioned is that in a busy office setting, scores of prior auth forms are received daily. Even when they are correctly completed, physicians are still faced with denials, phone calls, and long wait times on hold. Often, authorization requires a conversation with someone from the insurance company who is not a doctor or is a physician in an unrelated specialty. Then there are issues inherent to the fax process, such as a misdialed number or a fax received while a provider is away at a conference or on vacation. The requirement for a prior authorization is a time-wasting process whose best outcome is to stall payment for medications.

Who Is to Blame?

Did Walgreen's kill Yarushka Rivera?

At the least, her tragic death is a collective indictment of a healthcare system that failed her. MassHealth, and all other insurance companies that require prior authorization, should carry the brunt of the liability for harm that comes to patients unable to obtain a prescription if that inability stems from the prior auth process. Unless the physician has notified the insurance company of a change in therapy, the insurers should be obligated to cover the cost of the prescription.

Pharmacies and physicians' offices should never depend on archaic fax transmissions (the equivalent of carrier pigeons compared with newer communication portals). Pharmacists absolutely have a duty to communicate with physicians regarding patient care, especially when the failure to receive a medication can affect acute outcomes. In those instances, a phone call should be required. It is abhorrent that Walgreen's moved for a summary judgment in 2012, citing that it had no obligation to contact physicians in these matters. If that is truly its stance, then my faith in that system is shaken. Its obligation should be to patient safety. Patients and their families should be encouraged to advocate until they see results. If all else fails, they should walk into a physician's office or make an appointment to ensure the prior authorization process has been completed.

As for physicians, we have an obligation to respond to these requests in a timely fashion. I will state for the record, though, that many times we are accused of not filling out papers we've never received.

Yarushka Rivera's death should matter to all of us, not just as providers, insurance companies, or pharmacies but as human beings. No one should die from the lack of a signature.  A human life should never be lost due to a failed fax transmission or any failed communication when a prescription is active and efficacious. Let us hope and pray the legal system finds a way to abolish a need for prior authorization for maintenance medications that are working. That cumbersome process is far too great of a risk to take in a system that isn't.

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