Health Reform Must End the Harms of Prior Authorizations

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.

5 replies »

  1. An informative article discussing the real-time pains in the prior authorization. The shift for a proactive approach for value based care, time access to medication is only possible with valid health reforms and reducing the pains with administrative hassles.

  2. In my own personal experience of being the sole caregiver for my mother who had Hodgkins and Non-Hodgkin’s Lymphoma on and off for 15 years, I myself have witnessed the additional suffering she experienced caused by delays in receiving medications, as I dealt with her prior -authorizations. As she was too ill to deal with them herself. I completely agree that the amount of stress from the need for prior authorizations, especially delays in obtaining pain medications, sometimes is comparable to the stress of dealing with cancer treatment itself. Because I saw it with my own two eyes looking at my mother, who for years took 10 medications a day to stay alive.

    As a student at the CUNY School of Public Health in NYC, reading about the health care costs of $23 and $31 billion annually as a result of the time spent by health care providers to file prior authorization requests, was staggering to me.

    I feel that Dr. Blinderman’s proposed solution of an automatic “pre-authorized trial period” for all new medications, dosages, and quantities needed for pain or symptom relief in patients with life threatening illnesses is a great idea. It would help to alleviate patient’s physical pain and emotional distress of the patients and their families. It could also help to reduce the medical care costs such as hospitalizations that occur while patients are waiting for the prior authorization of their medications. The pre-authorization trial period can give physicians more control of the patient’s medication needs and things can overall run a lot smoother.

    Even though she is gone for 5 years, with a 3 day weekend like Memorial Day Weekend coming up, I still get butterflies in my stomach, because I think back about how the stress of obtaining a Prior-authorization was much more difficult during holidays such as this one- where HR offices etc close early, offices are closed, etc. All of the fighting and back and forth phone calls I had to do with HR at my Father’s job (she was on my Dad’s insurance), the insurance company, the physicians office, and the pharmacy. I am an only child, at least she had me to handle of all of this running around and phone-tag for her. But its baffling to me how they expect a sick patient to be able to deal with all of this.

    I can’t fathom this problem getting any better during the Trump Administration, as the AHCA didn’t exactly favor those who were sickest and needed the most help.

  3. “The way to stop preauths is in the hands of physicians, whether they realize it or not.”

    I wish you would expand upon this.

    When I ordered a CT or MRI it didn’t increase my profits though it did increase my expenses. Why do you think the tests were ordered?

  4. Good article Dr. B. While there ARE insurers (apparently) which use delay and deny as a tactic to reduce claims expense (“save money” has a different tone), most insurers which implement preauths do so only after there are observable abuses in physician orders. In my state of RI, we (Blue Cross RI) reluctantly implemented preauths for high end imaging only after rates of increase/member had had exceeded 25% for three successive years. Everyone hated the preauth procedure (of course), but the in terrorum effect apparently reduced the use pretty significantly, and we are relatively certain that no one who really needed an MRI or PET failed to receive it. Of course, that is difficult to prove conclusively. Could our process have been easier for physicians and staff? Probably; but consider what insurers are trying to accomplish while we continue to price ourselves out of the market due to rampant increases in rates of use of services. The way to stop preauths is in the hands of physicians, whether they realize it or not.

    Of course, stupid procedures that cause suffering patients to suffer needlessly should be avoided. And are there physicians who rile their patients up about preauths in hopes that they will complain? I’d guess so.

    But the excessive cost of health insurance is the elephant in the room, and we must find ways to reduce the rates of use of services or we may face an even bigger problem than preauths–that is the lack of insurance at all.

  5. AFAICT, this is largely the province of private insurance companies which makes this more difficult to change. Your examples are more dramatic than what I usually deal with, but when we changed insurers last year, many of my people (myself also) who had been on stable medication regimes for years had them disapproved by the insurer (Aetna). It took many hours on the part of many phsyician’s offices, my HR person and our staff to straighten this out. It may have saved the insurance company some money, but it sure cost everyone else a lot of time, and money.