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When insurance requires a prior authorization for a medication, the patient suffers

Updated: Aug 18, 2023

One third (33%) of physicians report that the requirement of a prior authorization (PA) in the care of a patient for a drug prescribed has led to a serious adverse event (hospitalization, permanent disability/damage, death, or other life-threatening event)


It goes without saying that our doctors today are overworked. On average they see somewhere around 20-30 patients a day. In an 8-hour day, that amounts to about 16 to 24 minutes per patient. Most of us have been to the doctor’s office and know they schedule us for 15 minute appointment windows. The 15 minutes we get with them obviously accounts for most of that time, but that’s not all. After you leave, doctors must still write their visit chart notes, order tests, coordinate with specialists, do research on the most up to date treatments, and worst of all, deal with the insurance companies.


Don’t they have someone to do that for them? Well, yes, in most cases. Slightly more than 1/3 of doctors report they have staff in their office that work exclusively on prior authorizations (PA).2 But that doesn’t mean the doctors can just hand it off to them and hope for the best. When medications are concerned, insurance companies want input directly from the doctor themselves, they want justification for why the patient needs the medication they prescribed and not some cheaper alternative. An office administrator won’t have the medical knowledge to argue with them, so it is foisted back on the provider themselves. Then the doctors must figure out which insurance company they are dealing with (it’s not always clear from the insurance card), fill out the right form, and fax it to what they hope is the right fax number. Trying to get medications covered through insurance companies takes on average 14 hours per week… almost two full business days. Imagine how much more time they could take with patients with those extra two days.


By requiring our doctors to deal with the insurance company directly in this manner, insurance companies take away from time that should be spent directly on patient care. In some cases, it is justified. In my experience as a pharmacy director for a health plan reviewing prior authorization requests, I have seen doctors make mistakes in prescribing medications, some of which could have caused serious harm to the patient. But the majority of the time, prior authorization is an unnecessary administrative headache that our doctors don’t need.


Nearly 90% of doctors report that they have a high or extremely high prior authorization burden. That shouldn’t come as a shock to anyone. But what should shock people is the unseen cost that burden has on patients like you and me.


One third (33%) of physicians report that the requirement of a prior authorization in the care of a patient for a drug prescribed has led to a serious adverse event. A serious adverse event is defined as hospitalization, permanent disability/damage, death, or other life-threatening events. Additionally, 64% report that a PA requirement has forced them to try an ineffective medication, 62% report they have had to have the patient come in for additional office visits, and 46% report that a PA requirement has led to the need for immediate urgent care and/or emergency room visits. One fourth (25%) of physicians report a PA has led to the patient needing to be hospitalized at some point in the previous year. As a former insurance administrator, I can tell you that’s the exact opposite of what they are trying to achieve. Even worse, 19% report a PA has led to a life-threatening event, and 9% report that a PA has led directly to a permanent disability/bodily damage and/or death. This was a survey of 1001 practicing physicians. If 9% of them are reporting that a PA has led to a life-threatening event at least once in the previous year, then at least 90 individual patients have had such a severe outcome from these doctors surveyed alone. That number is much too high.


What can we do? I think the only real way to make change is through laws and regulations. But that is not a quick process, and patients are suffering right now. That’s why I started this company. I can help you and your doctor cut through the red tape. I take that time that your doctor would spend working on a prior authorization and let him use it on actual patient care by working directly with you, the patient. I have over 10 years of experience in running the prior authorization programs for 3 different insurance companies, I know what the insurance company wants to hear, and I give it to them in terms they shouldn’t say no to. Let me help you avoid serious adverse events (or at least avoid having to go through unnecessary doctor’s visits). If you or a loved one has a medication that was denied due to a prior authorization, please contact me.




Sources

  1. How Many Patients Can a Primary Care Physician Treat? | AAPL Publication (physicianleaders.org) - https://www.physicianleaders.org/articles/how-many-patients-can-primary-care-physician-treat

  2. AHIP 2022 Survey on Prior Authorization Practices and Gold Carding Experiences available at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

 
 
 
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