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Tuesday Mar 08, 2016

Barriers to Care Persist for GLBT Patients

One of the great joys of being a family physician is providing care to everyone. On a recent -- and typical -- Tuesday, I managed a miscarriage, diagnosed atrial fibrillation, cheered a patient’s weight loss and started another patient on emtricitabine/tenofovir disoproxil fumarate (Truvada) for pre-exposure prophylaxis (PrEP).

With the gratification of direct patient interactions comes the mundane: the charting, FMLA forms and prior authorization paperwork. I've accepted it all as part of my career, as part of my advocacy and care for patients.

But I've also faced a glaring reality. Although the GLBT community has made tremendous progress in gaining equal rights, it still faces multiple barriers -- often surreptitious -- in the realm of health care.

I've recently noted an increase in prior authorization rejections, particularly concerning care for my GLBT patients. The reasons for the rejections are varied. I've had a few rejections for PrEP because I'm not an "HIV specialist."

That's unfortunate because providing this treatment has nothing to do with subspecialty care. The CDC has noted that primary care physicians can safely prescribe PrEP(www.cdc.gov), and leading HIV prevention groups have pointed out that there simply aren't enough HIV specialists to adequately reach all patients who could be on PrEP.

PrEP has been proven to reduce the risk of HIV infection in people who are at high risk by 92 percent(www.cdc.gov), according to the CDC. However, only about 30,000 Americans are using PrEP(www.aidsmap.com), although 415,000 may be eligible.

Primary care physicians also are facing prior authorization rejections for hormone therapy for transgender patients, with some payers demanding patients see an endocrinologist. Often, insurance companies won’t cover hormone therapy at all.

The prior authorization process, like so much of the bureaucracy of medicine, was created principally to curb spending. However, activity related to prior authorizations costs a full-time physician $3,430 a year, according to a study in the Journal of the American Board of Family Medicine(www.jabfm.org). The recent prior authorization rejections I have experienced were absurd barriers to care that didn't improve patient safety or control costs. Decisions like denying PrEP by a primary care physician in lieu of specialty care will ultimately cost more. In fact, studies have demonstrated the cost-effectiveness of PrEP(www.ncbi.nlm.nih.gov), so its widespread use stands to benefit insurance companies in the long run.

The promise of primary care to deliver on the Triple Aim is rooted in the ability of family medicine physicians to continue caring for diverse patient populations. An important study by the Robert Graham Center(www.annfammed.org) found that family doctors who provide more comprehensive care drive down health care costs.

Although it is a special privilege to care for GLBT patients, it’s not subspecialty care. Insurance companies limiting the scope of practice of family physicians for these patients is a dangerous precedent at a time when primary care doctors are needed the most.

So what do we do? I've written appeal letters. I've faxed the payers the CDC's guidelines and pertinent medical journal articles. In many instances, after several phone calls, the initial rejections were reversed.

Payers continue to wade into scope of practice issues, so in the best interests of our patients, physicians need to recognize and fight the health care barriers that come in many forms, including papers marked "prior authorization rejected."

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 10:03AM Mar 08, 2016 by Natasha Bhuyan, M.D.

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