In this episode, experts share their perspectives from their urology practices on addressing challenges such as insurance coverage, access issues, and the frequency of prior authorization (PA) denials and subsequent appeals. Co-panelists emphasize the need for additional information required by physicians to effectively appeal PA denials. Dr De La Cerda highlights the support his urology practice provides to meet the needs of his unique patient population.
Christopher M. Pieczonka, MD: So when you're writing for abiraterone, generally speaking for an mCRPC patient, are you just writing for the micronized version right to start with, or you know because I want to get your take on the process of the patient getting the medicine?
Jose De La Cerda, MD, MPH: Yeah, I usually do, and this probably has a lot to do with the fact that we have our own in-house pharmacy. So we carry both versions of abiraterone. And once they write the prescription, it's kind of a little bit out of my hands at that point. Our pharmacy really does whatever they can to ensure that the patients are getting what the physician wants. So they will go through the prior authorization (PA) process, they will send the documentation. They have the manpower to do that. But again, that's rare. That's, you know, not all practices work like that. So if I am able to get them this sort of micronized dose, I try to do that. Now, in the event that I'm not, I kind of just go to the standardized dose where I do the standard dose of 1,000 milligrams with prednisone in that sort of scenario. And I still send it to our pharmacy unless it's indicated in another pharmacy based on a patient's insurance or co-pay.
Christopher M. Pieczonka, MD: But if you're using the micronized version, it sounds like you are adding these little breadcrumbs for the pharmacy benefit managers to sort of destined to make it approved. But how often are you getting denials? Is it frequently, not frequently?
Jose De La Cerda, MD, MPH: Yeah, I'd say about 60 to 70% is still going to be a denial, even just because it's a non-generic medication. I'll at least start with it, just so I can, that way I know that I've at least maximized the opportunity of getting the doses like this.
Christopher M. Pieczonka, MD: And if not, can you go back to the generic form? And when you're getting those denials are you having to do a peer-to-peer? Are you putting a written appeal in? Just kind of give us a feel for how successful is that? How much time are you taking out of your day to do that?
Jose De La Cerda, MD, MPH: Yeah, so it can take hours out of the week, you know, at least one or two hours a day to try to get the patient the medication that they need to ensure that they live longer. And I think that's the most frustrating part when it comes to the right type of authorization and not of medicine these days. What I do is I see the reason it was denied. If the reason is better documentation, they're missing a CPT code, I try to do that. If they need to schedule peer-to-peer, I do that sort of that day or as soon as I possibly can, just because the longer that a patient waits for this, the longer they're going without treatment. And really, it's just so insurance-based and insurance-dependent. It's just the reasons I've seen so many different types of reasons from documentation, from alternative prescriptions, or totally switching to something like they want to do, ends a little mind instead. So it really blows my mind with things that I see out there. And sometimes trying to get to the bottom of the line of where they get this evidence, nobody really knows. And I think that's what kind of frustrates me the most.
Christopher M. Pieczonka, MD: I'm really interested in the practice support relative to the nature of your particular patient population. You indicated that a lot of your patients identify as being of Hispanic descent, but how many are non-English speaking? What percentage and how do you deal with that? In my neck of the woods, it's kind of not much of an issue. So I want you to just kind of walk us through that. That's really interesting.
Jose De La Cerda, MD, MPH: I actually speak Spanish more than I do English at work. There are only about three Spanish-speaking urologists here within the practice. I get the gamut of all the Spanish-speaking urologists, and so most of my patient population only speaks Spanish. They're lower socioeconomic status. They're from sort of disparate locations, so I'm able to break through that communication barrier. But that's sort of the benefit that I have, and that's why I see these patients, because once you're able to communicate in their language, there's an automatic trust. They say, "Oh, we understand each other." There's really no doubt whenever we're coming up with the plan, and the patients are much more compliant and they're willing to take the medication, even if it makes them feel a little bit crummy. And I think I break through that very well because of that. Now, all our satellite clinics, we have Spanish-speaking medical assistants and advanced practice providers (APPs). So luckily in this sort of geography, we're able to get a lot of patients and a lot of physician support that speaks for itself.
Christopher M. Pieczonka, MD: And I assume you have literature both in English and in Spanish for, you know, your prostate cancer clinic.
Jose De La Cerda, MD, MPH: Some pharmaceutical companies do better than others. And some pharmaceutical companies, I do have literature in Spanish, but others, they don't have it available. Or it needs to go through some sort of processing. But the literature, they might have it, but sometimes it's difficult. I mean, these are Spanish speakers, but a lot of the time they might not understand, you know, beyond like a fourth, fifth-grade sort of reading level. And so even though it's there, they really might not understand it unless it's easy to read and in Spanish. So those are all sort of little nuances. I come with having an APC clinic and sort of these very diverse and Hispanic populations.
Christopher M. Pieczonka, MD: Kind of off topic, but it's interesting to me. So when you have your clinical-based research, are you offering and doing research studies for Spanish-speaking patients only?
Jose De La Cerda, MD, MPH: Well, we're doing English and Spanish, but we have central and local Institutional Review Boards (IRBs), and they do all the translation for documents, so we're able to kind of do the diversification, because right now, for all these trials, the FDA is really harping on ensuring that we're getting a diverse amount of patient population, particularly black men. I mean, black men have more aggressive disease, they have more advanced disease, but they're the most underrepresented, and I think in a lot of these countries, trials and a lot of APC clinics.
Christopher M. Pieczonka, MD: Yes, that's fantastic. Alright, so there are people like us who do doctor stuff, and then there are people who count beans. Right. And my question is, when the pharmacy service line is being looked at, walk me through the potential benefit of generic versus branded product. Is it a favorable thing is it not a favorable thing does the accounting people say hey. "Hey, why are you doing the micronized version?" Maybe just kind of share that.
Jose De La Cerda, MD, MPH: Yes, so it's certainly favorable for us. It all depends, and we're a part of a Group Purchasing Organization (GPO), so we work with GPO. We work with rebates and reimbursements. We want to do what's best for the patient, number one, but at the end of the day, we're also a group that employs over 400 people, and we want to ensure that we're able to sort of maximize the way our group practices and our group runs and the economics of the group. And so if there are particular medications that are effective for the patients, then they're also pretty supportive for our clinic and our practice and the people that we employ. We definitely want to maximize all that as a large urology practice.
Christopher M. Pieczonka, MD: Yeah, we found the same thing. You know, we're a little bit different in that in New York state, we have something called a medically integrated dispensary. So the physicians and the group cannot own a pharmacy, but this harkens back to the days of pharmacists and physicians being the same thing to the mortar and pestle days. And so we're able to, in New York state, if a patient is under a cancer protocol or an HIV protocol, provide them a medically integrated dispensary. So we don't do narcotics because it's complicated. So well, we're kind of in the same, you know, it's kind of the same service line. So things that are you know, are always looked at because we are a business to find out and make sure that we're not losing money, that we're not, sort of donating our service and our time just because of the difficulty that we have with making money, seeing patients with Medicare, you know, there's a constant drain on trying to, you know, decrease the bottom dollars and the professional services and that's challenging. So we have the same sort of favorable look for usage of the branded product.
*Video transcript AI-generated and reviewed by Urology Times® editorial staff.