A not-so-new evil has risen to the top of the most disturbing concerns for physicians. No, it’s not EHRs; it’s prior authorization of medical services. As most licensed health care professionals know, prior authorization rules require clinicians to receive permission from a health insurer before approving certain patient services. In the case of medications, prescribers must get the go-ahead from the health insurer before the pharmacy can dispense the prescribed medication.
About six years ago, I herniated a lumbar disk, resulting in a painful radiculopathy. I couldn’t walk. Conservative measures, including physical therapy, failed to improve my symptoms. My neurosurgeon scheduled me for a lumbar discectomy. I received a letter from my insurance company the day prior to surgery stating that my operation had not been approved because the insurance company’s physician failed to see the pathology on my MRI.
I called my neurosurgeon in a panic. He spoke to the reviewing physician. It turns out the insurance doctor failed to appreciate that I had an uncommon type of herniation — a far lateral disc herniation. The procedure was subsequently approved by the insurance company.
Did I need this grief the day prior to spinal surgery? Did my doctor need to interrupt the flow of his surgical cases to lecture an untrained insurance reviewer? And what gives insurance company physicians the right to play armchair quarterback and second-guess the treatment of physicians in the trenches who know their patients firsthand?
More recently, my insurance company required prior authorization of an antihypertensive medication I had been taking for nearly 20 years. The medication is generic and is itself a combination of two generic medications. How much money would the insurer save by denying me my medication? Answer: hardly anything. How much money would it cost the insurer if I was forced to forego treatment or forced to take another, less effective pill and, God forbid, ended up having a stroke or heart attack? Answer: a substantial amount in punitive damages awarded in bad faith litigation.
Rather than fight the insurance company, I suggested to my doctor that he prescribe the individual generic components of my antihypertensive pill. Guess what? The insurance company approved it. No prior authorization was required. Is there any value to this exercise? Certainly not for me, and probably not for the insurance company, which failed to recognize how the system can sometimes be manipulated by a workaround.
Let’s face it. Medications and medical services are expensive. Health plans think medical costs can be reduced — and profits increased — by preventing certain types of procedures or tests they deem unnecessary, or by substituting less expensive drugs than originally prescribed.
However, a survey by the American Medical Association (AMA) in December 2020 found that prior authorization requirements can be harmful to patients. Of the 1,000 physicians surveyed by the AMA, 30% reported that prior authorization has led to serious adverse events in patients under their care, from hospitalization to permanent impairment. Other notable findings include delayed access to care, treatment abandonment due to frustration with the process, and an additional two business days of physician and staff time to contend with the hassles.
As the COVID-19 pandemic peaked, prior authorization’s detrimental effects continued. Many insurers temporarily relaxed their policies, only to revert to business as usual by the end of 2020, as COVID-19 cases hit record highs. Access to needed drugs, tests, and treatments was thwarted, according to 70% of physicians in the AMA survey, with nine out of 10 physicians reporting that prior authorization requirements had an overall negative effect on patient outcomes.
Approximately one-third of survey respondents believed that prior authorization criteria were rarely or never evidence based, yet virtually all health plans report they use peer-reviewed and evidence-based studies when designing their programs. So, is the intent of these programs to cut costs or improve quality of patient care? The answer is: probably both. But how can one avoid skepticism given the skyrocketing costs of new technologies and the onslaught of cell and gene therapies? The first new drug in 18 years approved to treat Alzheimer’s disease (a biologic) costs $56,000 a year, and it’s not even a cure.
Physicians must also deal with a plethora of low-value prior authorization requirements that, quite frankly, are a waste of time because neither the clinical nor financial yields from treatment are significant.
The AMA has chronicled the injustices of prior authorization and is attempting to rightsize programs so that physicians can focus on patients rather than paperwork. In 2018, the AMA and other organizations developed a consensus statement outlining a way forward. Health plans, however, do not appear to be on board. Not even a global pandemic can shake some sense into them.
Share your experiences with prior authorization in the comment section.
Arthur Lazarus, MD, MBA was a 2019-2020 Doximity Community Fellow. He is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.