BLOG: Prior authorizations deny patients necessary medical care
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Our health care system is broken on multiple levels.
As a medical community, we somehow seem to be hastening its untimely demise by continuing to partake in systems that waste inordinate amounts of time and result in the delivery of suboptimal patient care, such as the burdensome, inefficient, time-consuming and overall unnecessary prior authorization system.
A perfect storm
The prior authorization system is extremely harmful to patient care and results in unnecessary delays and disruptions. As described by the AMA, the prior authorization system costs valuable time, comes between the physician and patient, undermines the physician’s expertise, does not put patients first and prevents patients from receiving the care they need.
How many hours do you think a physician, nurse, nurse practitioner, pharmacist and many others spend (waste) on the phone, justifying care through peer-to-peer calls and dealing with prior authorizations? How many patients’ care have been delayed because of prior authorizations or peer-to-peer denials for necessary treatments?
We must also factor in further delays due to an overall inflexible system for responding to these prior authorizations that do not consider the incredibly busy practices of clinicians and the myriad of other responsibilities needed to be completed during the day.
Add into that antiquated communication systems — yes, we continue to use fax machines and pagers in health care settings — severe burnout as we enter year 4 of an ongoing pandemic, significant staffing shortages, supply chain issues and an overall breakdown of our health care system, and we have a perfect storm.
Arduous process
The prior authorization process was set up to minimize waste and allow for plans to evaluate whether care is medically necessary. The argument consistently made by insurance companies is that unnecessary testing, interventions and medical care are ordered, and the insurance company should be able to determine if the care is necessary.
This process, in fact, does the exact opposite and often results in denying patients cutting-edge, and sometimes even standard, medical care.
Medical care, especially in fields like oncology, often moves faster than insurance company protocol builders. The prior authorization system results in the delay or ultimate denial of care that should be approved and, in some cases, started in an expedited manner.
It is not only new drugs or imaging modalities that are denied or deemed necessary for prior authorization. Standard-of-care therapies and interventions can also be forced to undergo the prior authorization process. In some cases, the process results in denying care that the patient has been receiving for years, but because of changes in the insurance company protocol, a new prior authorization is needed for justification.
All of these barriers to providing care in a timely manner result in unnecessary delays and added stress for patients and for health care providers, who must dedicate the time needed to go through an often arduous and unnecessary process. In many situations, the individual making the decision to deny care is not even an expert in the field in which the care is being provided, and insurance company protocols and policies are often not as up to date as the physicians providing the care.
The ultimate result is physicians and health care teams waste countless hours on the phone, justifying how we, as health care providers, are delivering the care for which we have been trained and board certified to provide.
I hear of physicians being applauded for going the extra mile for a patient and fighting for a particular drug or test. When that process must be undertaken for most patients in a clinic, there are simply not enough hours in a day to provide exceptional patient care and fight to make sure the care is then approved through the insurance carrier and ultimately delivered.
The system that is currently in place does not help patients receive the best care possible; instead, it has been created to save money for the insurance companies.
Many physicians simply do not have the time to go through the lengthy and often inconvenient prior authorization process for each patient, which is a win for insurance companies. They no longer need to pay for the care that was deemed necessary by a medical provider. Some physicians have simply given up on going through the process. I know of some practices hiring team members to solely deal with the prior authorization process — a waste of resources and money.
Salvaging a broken system
Physicians providing care are required to train for many years in medical school, residency and, in some cases, fellowship, and are required to have board certification in their area of expertise.
Why are we trusting individuals with no expertise or medical training in the field to make life-altering decisions over the actual medical experts who deliver the care? If we don’t trust our physicians to order medications or interventions or tests, why go to the doctor at all? If insurance companies know best, we should simply remove physicians and doctors’ offices from the equation, and insurance companies should be the ones diagnosing and providing care.
To be sure, there are some clinicians providing care that may not be up to standard, and there should be systems in place to address those issues. But to punish an entire health care system because of a few bad actors does not produce the desired result; instead, it results in suboptimal care for patients across the country.
In a nation where we pride ourselves on being at the forefront of science and medical care, it is counterproductive to deny care because insurance companies’ protocols have not yet been updated, or because, simply put, the insurance company does not want to pay.
As we enter year 4 of an ongoing pandemic, the massive cracks, inefficiencies and gaps within our health care systems have been laid bare. Now is the time to repair our system, and rebuild the foundation of patient care, with a focus on the doctor-patient relationship. It is past time to shift back toward patient-focused care. Getting rid of an arduous, dysfunctional and faulty process like the prior authorization system is a good first step in making the changes needed to salvage a broken health care system.
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Shikha Jain , MD, FACP is an associate professor of medicine with tenure in the division of hematology, oncology and cell therapy at the University of Illinois Cancer Center in Chicago and Healio Women in Oncology’s consulting medical editor. She can be reached at sjain03@gmail.com.
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