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“Should Indiana prohibit prior authorization in health care?”
A patient with asthma is denied coverage for four different inhalers, being told each time to request one of the other three instead. An insurer insists acid reflux medication will be approved only as a capsule, not a liquid—even though the patient is a baby. A patient is denied coverage for an MRI and told to try physical therapy, for what turns out to be a herniated disc.
Every physician has countless stories of how patient care has been obstructed, delayed or prevented by prior authorization, the process of requiring review of prescribed services before health plans approve coverage. However, a system designed to prevent unnecessary expenses is instead creating them, while causing patients needless pain.
Even when prior authorization “works,” it drives up costs and reduces the hours available to treat patients. An AMA survey found physicians and their staff spend an average of 12 hours a week on prior authorization; 35% have hired staff for the sole purpose of navigating the mountains of paperwork that accompany even straightforward cases.
And those are the good days. Prior authorization plunges many patients into a bureaucratic nightmare. Patients with migraines who found the right medication after years of searching have been told to go back and try medications that have already failed. Patients with severe heartburn have been unable to eat for days because of prescription denials. Diabetic patients have brought their weight and blood sugar under control, only to see them balloon again because an insurer refuses a prescription refill on the grounds that their improved numbers showed they “didn’t need it.”
Prior authorization is not inherently problematic but is badly in need of common-sense reforms. A better system would begin with more timely decision-making. Patients are enduring days or weeks of unnecessary pain while awaiting approvals that should be automatic.
A second pillar of prior authorization reform must be transparency. Many of the obstacles encountered by patients and physicians result from authorizers treating medicine as a trade secret. Physicians know which drugs or procedures their patients need but are forced to guess whether those treatments will be approved. Worse, patients might change insurers or pharmacy benefit managers (PBMs) might change their own standards, leaving physicians to figure out the new rules.
Insurers have additional options to dramatically reduce patients’ pain and frustration. Treatments below a given cost threshold could simply be exempted from prior authorization requirements. PBMs should establish and adhere to a formulary that makes clear which medications are covered. Similarly, insurers, in collaboration with physicians, could create a checklist of circumstances where a drug or procedure should be approved automatically. If coverage is denied, physicians must have prompt access to peer-to-peer appeals, allowing review by a physician in the same specialty.
Everyone knows the oldest and most fundamental rule of medicine: “Do no harm.” Prior authorization has repeatedly failed to pass this basic test. Physicians dedicate their lives to putting patients’ well-being first, and there is no reason prior authorization cannot do the same.•
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Pond is president of the Indiana State Medical Association. Send comments to ibjedit@ibj.com.
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