Are prior authorization insurance requirements killing patients?
By Barbara McAneny
Mar 20, 2019 | 6:00 AM
Colin J. Haller was smart, funny, ambitious and athletic. And he was just 25 when he was diagnosed with metastatic melanoma.
The Maryland native had already launched a successful internet marketing business. An outstanding student, he was applying to medical schools to pursue his dream of a career in medicine when he got that terrible news. His treatment plan called for scans every three months to assess the progress of this deadliest form of skin cancer.
But that didn’t happen.
It didn’t happen because Colin’s health insurance plan included a prior authorization requirement, which meant his physician needed to secure approval before each scan could be performed. The paperwork and processing time that ensued meant that each imaging test Colin needed was delayed by as much as a full month.
As Colin and his care team pressed their fight against a deadly foe, prior authorization was again needed, this time for immunotherapy drugs. After more delays and an unsuccessful clinical trial, Colin’s physician recommended a newer immunotherapy drug — but Colin died two weeks before he could begin receiving treatment. He was just 28.
“I have often thought, in retrospect, after my son passed away, if the scans had been done on time, maybe it would have been caught sooner,” said Colin’s mother, Linda. She also wonders what would have happened if his drug treatment hadn’t been delayed. “Possibly, it could have saved his life.”
Colin’s story is both tragic and all too common. As a medical oncologist with a full-time practice, I deal with treatment delays and other consequences of prior authorization every day.
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And physicians across the nation believe the problem is getting worse. An AMA survey of 1,000 physicians completed in December found that more than nine in 10 said prior authorization rules had a negative impact on clinical outcomes. More than a fourth of respondents said these requirements had triggered a serious adverse event — a hospitalization, permanent injury or disability, or even a death — for a patient in their care.
Health insurance executives will argue — wrongly — that prior authorization has benefits that offset the human costs they engender. Insurance companies contend that prior authorization is necessary to ensure policyholders receive safe and efficacious treatment, and that health care costs are contained.
To us, the cost containment argument rings hollow. Denying a prescription or test might save money in the short run. But when a patient must be hospitalized due to a lack of timely treatment, those cost savings will be wiped out many times over.
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The AMA has and always will support the practice of evidence-based medicine tailored to the unique clinical characteristics of each patient. Physicians must be good stewards of limited health care resources in every situation. But the prior authorization process in place today must be overhauled to eliminate treatment delays that inflict tremendous harm and needless suffering on our patients. This is dysfunction in our health care system that interferes with patient care.
The burden of prior authorization is also at odds with the tenets of value-based care. The AMA survey cited above found that physicians completed an average of 31 prior authorization requests each week. That workload alone consumed nearly two days of physician and staff time which could otherwise be spent caring for patients.
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In January 2018, the AMA — along with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association — released the Consensus Statement on Improving the Prior Authorization Process. This document outlined the key reforms needed to ensure timely access to care, including a reduction in prior authorization requirements and increased processing automation. It also promoted greater transparency and protected continuity of care.
Prior authorization processes should be evidence-based, transparent, electronic and immediate. The plans should monitor their prior authorization processes and remove that requirement entirely when they find that a procedure is never denied or a practice is never denied.
The Consensus Statement represented a landmark agreement to resolve a longstanding conflict between physicians and health plans.
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But the results have been disappointing. In additional survey results released last week, physicians report an increase in the number of prescriptions and procedures that require prior authorization. And fully 85 percent said prior authorization is still disrupting continuity of care. Even progress in automation — the one area health plans seem most interested in addressing — has been slow to materialize.
It’s time to fix prior authorization. Physicians know it, the AMA knows it, the family of Colin Haller knows it. And we won’t stop spreading this message until insurance companies know it too.