Patently Absurd Passive Aggressive Prior Authorization Approval


In my solo practice, I complete the medication prior authorizations, and frankly, sometimes the indignation gets the better of me and my contrarian tendencies emerge. The following are all actual responses that have been submitted. Some are humorous, some obnoxious, and some completely nonsensical, yet they ALL resulted in approval. What exactly does that say about this ridiculous process? You be the judge.

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Under What Part of Gun Safety Does Pharmaceutical Benefit Manager Anti-Kickback Protection Fall?

August 10, 2022

Insurance Company to Doctor: "Please explain why your patient needs the prescribed medication instead of one of the preferred formulary alternatives."

Doctor to insurance PBM: "Please explain to me the kickbacks that you receive via rebate sharing, pharmacy spread, DIR fees, pass-through administrative fees, reimbursement rate, and the PBM-owned pharmacy profit margin differential related to the prescribed medication and all formulary alternatives and exclusions, and then we can see who should be asking the questions."

In case you had not noticed, on page 21 of the 32-page "Gun Safety Bill", a section unrelated to firearms reads: "Extension of Moratorium on Implementation of Rule Relating to Eliminating the Anti-Kickback Statute Safe Harbor Protection for Prescription Drug Rebates." In other words, let's not just take steps to reduce gun violence, let's also give PBM's another year of legally violating anti-kickback laws so they can continue to rip us all off until January 2027.

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Direct Primary Care – A lifeline for physicians

August 3, 2022

Last month I attended a three-day Direct Primary Care (DPC) conference in Kansas City, demonstrating the major growth in this movement to free the practice of medicine from corporate swindlers and return it to patients and their independent physicians. Or, as keynote speaker, Dr. Doug Farrago has subtitled his decades-running blog, "Taking Healthcare Back from the Idiots Who Are Now in Charge."

Of the 260+ physicians in attendance, I would venture to say that the show of hands corresponded well to the look on their faces in determining what stage of converting their practice to DPC folks were in – About 60% were owners of their own independent practice (the happy ones, with heads held high, welcoming smiles and enthusiastic candor).  Twenty percent were planning to open their practice within a year (the ones with the wide, nervous eyes holding on to every word for pearls of wisdom).  Fifteen percent were in an early exploration/planning stage (the "DPC curious" were the tired-looking huddled masses, afraid of the unknown, yet yearning to be set free).  And there was a large handful of medical students and residents there, too (the boisterous younglings, ready to jump into the fire with unabashed ambition).

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Monkeypox and Reader's Digest

May 25, 2022

When the news headlines and even my YouTube feed started blowing up this week about Monkeypox, I had a flashback to my second year of medical school. The memory had nothing to do with microbiology or the pathogenesis of the orthopox virus. It was a story shared by my pathology professor, and though probably fictitious, it is nonetheless amusing and relatable. 

Dr. Thorne was the only doctor in a small rural Maine town for the latter half of the twentieth century. One day, shortly after noon, his wife, Mary, was surprised to hear him enter the house and rush up the stairs to the bathroom.

“Is everything okay, dear? I thought you had a full day at the office,” she inquired.

“Yes, yes. I’m fine. Have you seen the Reader’s Digest?” he shouted down to her.

“It should be there on the shelf,” she offered.

“No, that’s last month’s issue” he grumbled as he moved on to search the bedroom. “Ah, here it is,” he announced as he headed for the front door. “I haven't read it yet, and Mrs. Winslow is coming for her appointment in half an hour!”

“Mrs. Winslow?” Mary asked. “I’m sure she has her own subscription.”

“Precisely,” said Dr. Thorne. “She always comes in with the strangest symptoms, and the only way I have any clue what she is worried about is by knowing what rare disease was featured in the latest issue!”

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Art as an Expression of Medical Practice

May 4, 2022

With last week being school vacation for most of New Hampshire, my wife and I took our 11- and 13-year-old kids down to Washington, D.C., for a few days to see the sights and make the rounds of the monuments, museums, and historic buildings. I was particularly taken by our visit to the Hirshhorn Museum’s outdoor sculpture garden set beside the National Mall. On display were works from Rodin, Jean Arp, Henry Moore and others. It had been many years since I last immersed myself in such works of art, and I found myself engaging neural pathways that had long laid dormant. Connecting shapes, light and texture, considering the artist, the titles, the context – it was a captivating experience to appreciate the beauty and tease out the meaning of these enduring pieces.

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March 23, 2022

The second anniversary of the COVID-19 pandemic has sparked retrospectives and tallies of all sorts – in number of COVID-19 cases, deaths, and people with long COVID symptoms, as well as the excess mortality from all causes during the pandemic.

One elusive number, however, is the number of healthcare workers and physicians who died by suicide over the last couple years. On average, 300 - 400 physicians die by suicide every year. But we all know that the stress brought on by the COVID-19 pandemic has been unlike anything we have faced in our generation, and that number is likely higher. Following the loss of Dr. Lorna Breen who was medical director of the emergency department at New York-Presbyterian Allen Hospital to suicide, a grassroots effort to improve physician well-being was amplified by national advocacy efforts, and The Dr. Lorna Breen Health Care Provider Protection Act was signed into law last week by President Biden. 

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On Vaccine Hesitancy: Making A Deposit in the Emotional Bank Account

January 26, 2022

Despite working in solo family practice, I know I’m not alone in my efforts and frustrations with trying to vaccinate the unvaccinated against COVID. If one focuses on the picture painted by the news or social media, it is trench warfare with both sides dug in deeply. But the reality is more nuanced, and many patients find themselves stuck in no man’s land, not knowing who to trust. If we remain open and listen compassionately to the story behind each individual’s hesitation, there are still opportunities to make a difference. I will share one recent story that provided me with a little dose of positive emotional energy to remind me why I love primary care, and why I’ll continue to take on the challenges of this pandemic to keep my patients thriving and out of the hospital, one patient at a time. 

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Affecting Positive Change

January 5, 2022

The turning of the new year usually brings with it a mix of retrospection and hopeful resolution.  2021 was a year that more than a few people would rather wipe off the books. Just watching the Netflix mockumentary "Death to 2021" was causing me to have palpitations.  If you are struggling to be optimistic about 2022, or even considering throwing in the towel yourself, you are not alone, but not without hope.
It might be just one thing, but it’s up to each of us to decide what we want to see, and how we can affect that positive change this year. Some will think big and take steps towards global issues. Others may try to shape the effects of local politics.  As physicians, our actions and decisions will absolutely impact healthcare. Maybe your goal is to just get through. That’s completely OK. But the way we choose to look at our day-to-day experiences shapes how we feel about all of these things.

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Dr. Eric Kropp Inaugurated as 190th President of the New Hampshire Medical Society

Eric A. Kropp, MD, was inaugurated as the 190th president of the New Hampshire Medical Society during its 2021 Annual Scientific Conference held at the Omni Mount Washington Resort in Bretton Woods, succeeding anesthesiologist Dr. Kenton Allen.

In 2016, Dr. Kropp started his solo practice, Active Choice Healthcare, in Concord as a pioneer in Direct Primary Care and fostered New Hampshire law about this innovative and emerging medical practice model. He is a founding member of both the New England and National Direct Primary Care Alliances.

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Cultivating effective physician leadership across the Granite State

May 11, 2021

This past Monday, the Spring meeting of the Council of New England State Medical Societies was held virtually via Zoom. The meeting is held as a platform to share successes and challenges and to support one another as stakeholders in the public health of our region.

Each Medical Society President prepared a report for the delegation and there were several themes that were shared in response to the events of the last six to twelve months. Advocacy around the future of telehealth, COVID-19 vaccine educational initiatives and social determinants of health were priorities amongst  most of our fellow societies.

However, the theme that was most striking amongst the reports was the importance placed on the need for physician leadership and the efforts being made to provide physicians with the opportunity to more readily gain access to these positions. 

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