As the White House continues to push for a revised Republican proposal to replace the Affordable Care Act (ACA), one thing is for certain, many of the sickest Americans will continue to suffer as they are denied medications and other treatments under current health insurance strategies to save costs.
Both the ACA, and the recently proposed MacArthur Amendment, do not address a well-established practice of health insurers’ use of restrictive prior authorization requirements to deny or delay coverage of medications and treatments to seriously ill patients. In my own practice caring for cancer patients and those with terminal conditions, I have witnessed the additional suffering caused by denying these patients timely access to medications for pain.
A prior authorization is essentially a check run by insurance companies or other third party payers before approving certain medications, treatments, or procedures for an individual patient. Insurance companies justify this practice as a means to save costs to consumers by preventing unnecessary procedures from being covered, or requiring generic drugs to be used instead of brand-name, more expensive alternatives.
On the surface, this may seem like a laudable goal given our rising and unsustainable costs associated with health care. However, when one looks at the impact prior authorizations have had on our U.S. health care system, it is estimated to cost between $23 and $31 billion annually as a result of the time spent by health care providers and others to file prior authorization requests and then submitting appeals when the initial requests are denied. Additionally, medical costs have been shown to increase as a result of more emergency room visits, outpatient visits, and hospitalizations.
But the financial cost is only one component of our calculus. There is also the cost to our patients and their families—the physical and emotional suffering that ensues from this process. And, to be sure, it is significant, but difficult to quantify.
I once asked a dear patient of mine who recently passed away from colon cancer, Kristen McRedmond, teacher, blogger, traveler, surfer, and an inspiration to her many friends and family, to describe her experience with prior authorizations.
When you are diagnosed with cancer, many thoughts run through your mind. For me, the initial questions were: Will I survive this? Will my family survive this? Will these treatments destroy me? Will I be able to afford this? Will my health insurance pay for what I need? The last two questions seem like they have a ridiculous place sitting next to the first three. But if I were to be honest, the amount of distress that I have incurred from the need for prior authorizations—most significantly, delays in obtaining necessary pain medications—have been comparable to the distress of dealing with cancer and its treatment.
Delays in obtaining adequate medications for pain and other distressing symptoms, like shortness of breath, by using less effective or lower strength medications, or insufficient quantities of an effective drug, inevitably lead to inadequate pain and symptom relief. This is something Kristen and many others have experienced, and is widely feared by most Americans—that we will spend our last days in pain.
One solution to this problem is instead to have an automatic “pre-authorized trial period” for all new medications, dosages, and quantities needed for pain or symptom relief in patients with cancer or other life threatening illnesses. Following this trial, there could be a required certification process to provide sufficient justification for continuing a given therapy. The justification could include clinically relevant patient outcomes, like reported pain or symptom relief, physical or mental functioning, as well as important health care cost reductions, demonstrated in reduced emergency room or hospital visits. This would likely empower clinicians to have more control over their patients’ care, adopt cost effective strategies for pain and symptom management, and reduce the anxiety and unnecessary suffering of seriously ill patients who worry that their medications will not be covered.
Considered analysis and pragmatic interventions are necessary if we want to reduce health care costs and the harms associated with current health insurance practices. Failure to address the deliberate denial of palliative treatments to save costs sends a signal that this is an acceptable strategy.
Americans facing a serious illness deserve better.
Craig Blinderman, MD is Director of the Palliative Care Service at Columbia University.