Prior authorization is another barrier to cost-effective care

107 Shares

The Affordable Care Act, aka “Obamacare,” has improved patient’s access to health care since its passing in 2010.

The increase in coverage, however, does not address the restriction of prior authorization (PA), where a physician is required by a patient’s insurance company to obtain special approval from the insurance company for a medication or treatment. PA is not only needed for medication, but also for scans, potential surgery, and even for radiation.

The PA process involves being told that a service requires PA, receiving a specific phone number or address in order to request PA. When a PA is denied, the physician can make an appeal. This process can take several hours and delays necessary treatment. Studies have shown that a physician spends approximately three hours weekly on PA, and nurses spend even more, with a national time-cost estimate of $23 billion to $31 billion annually.

The American Society for Clinical Oncology or ASCO endorsed a bill this past spring 2019 in order to streamline PA. This bill, applauded by various organizations, was passed in order to facilitate adequate medical care and decrease unnecessary delays.

Last year I saw a 10-month-old boy* with gastrointestinal reflux disorder, otherwise known as GERD. He had multiple medical complications, including a gastrointestinal tube for feeding, and his gastroenterologist started him on a proton pump inhibitor, a medication used to decrease the amount of acid in the stomach. He was on this medication throughout his hospitalization after having his G-tube placed and was able to tolerate his feeds well.

When I saw him at his post-hospitalization visit, his mom was extremely concerned about his constant vomiting with each feed. I quickly learned that my patient’s medication required PA, which included having me fill out several forms; what followed was a rejection letter and instructions for me to appeal by speaking with a representative on “a physician level.” Not only did this result in a tremendous amount of time and effort, but the medication was also eventually denied, and I was forced to prescribe a different, less effective medication.

One could argue that there are other medications that can help treat GERD, but as a future pediatric hematologist-oncologist, I’m concerned this trend is spreading.

Last winter, I cared for a young woman* with a soft tissue tumor, who required both inpatient and outpatient medications to treat her cancer. She was enrolled in a Children’s Oncology Group (COG) protocol, which dictated specific days that she received chemotherapy and supportive medications. The COG protocol actually discussed when to give Neulasta (pegfilgrastim), a medication used to stimulate the bone marrow to make more white blood cells.

Due to PA, we couldn’t be sure that she would have access to this medication at home. Instead, she stayed inpatient for several days longer in order to ensure she had received this medication on time. Ironically, her insurance company paid significantly more for her prolonged hospitalization, in lieu of paying for the medication itself on an outpatient basis.

Right now, there aren’t any easy solutions to PA.

There must be a way to ensure our patients on, and off protocols have appropriate access to their essential medications. Our current system is not providing cost-effective care to our patients.

Many organizations are lobbying to improve this widespread problem. The American Medical Association (AMA) has most recently written an act to ensure transparency, all while addressing the importance of not delaying medical care due to PA.

Paul Harari, MD, FASTRO, Chair of the American Society for Radiation Oncology, shared: “While the system was designed as a path to streamline and strengthen access to treatments, it is in fact frequently harmful to cancer patients prescribed radiation therapy.” Right now, we need to continue to work with our legislature and provide concrete examples to help facilitate a streamlined effort for PA. In August 2019, the House of Representatives introduced a bill to improve seniors’ timely access to care, ensuring that unnecessary PA would not stand in the way of providing care.

I am hopeful that these efforts will be rewarded in the near future, and PA will no longer be a hindrance for patients seeking the medical care they need.

* Patient details changed to protect privacy.

Rachel Offenbacher is a pediatrician.

Image credit: Shutterstock.com

107 Shares

View 7 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories