But in recent years, some insurers have started requiring prior authorization even for low-cost generic drugs, said Andrew Spector, a neurologist who specializes in sleep medicine at Duke Health. The anti-seizure medication that worked for Doraiswamy’s patient is expensive. In the ensuing decades prior authorization was extended to new high-cost drugs. The idea that insurance companies could influence how patients should be treated emerged in the 1980s, when insurers began requiring pre-approval for some hospital admissions and high-cost procedures before they would agree to pay for them. With the help of legislation like his, Bera said, “We could actually move the pendulum back towards doctors taking care of patients.” (The AMA, as well as health insurance companies and their trade groups, donate to both major political parties and are among the top spenders in lobbying Congress.)īera says that, since the vast majority of prior authorization requests are eventually authorized, insurers’ overzealous use of the strategy merely delays care and wastes physicians’ time instead of saving the health care system money.
Nearly 300 members of Congress have since signed on to the House bill or a companion bill in the Senate. In 2021, Congressman Ami Bera, an internal medicine physician, joined three colleagues to introduce a bipartisan prior authorization reform bill. But, as drug prices rise, insurers are intensifying prior authorization requirements and physician practices have built up a huge infrastructure to fight for the drugs they want to prescribe.įrustrated physicians are turning to state and federal legislators, hoping elected representatives will force insurers to curtail the crushing burden of faxes and phone calls needed to get permission to do what physicians think is right.
(Other strategies include patient cost-sharing and requiring patients to try low-cost drugs before the insurance company will pay for a more expensive therapy.) These strategies can discourage the use of inappropriate and overpriced medications and promote the use of better options. Perhaps counter-intuitively, prior authorization is one of several strategies that insurers use to reduce wasteful medical spending. The average physician must now seek approval for dozens of prescriptions and medical services each week, an administrative burden that contributes to burnout and costs physician practices an estimated $26.7 billion in time each year. Prior authorizations also exact a toll on doctors, who say the paperwork has gotten out of hand. Physicians want laws to curtail the crushing burden of faxes and calls insurers impose on them as a requirement for coverage. Just over half of the physicians who treat adult patients in the workforce said prior authorization has interfered with patients’ ability to do their jobs. In that same survey, more than 80 percent of surveyed doctors said patients at least sometimes abandon their recommended treatment because of prior authorization hassles. In an American Medical Association survey conducted in December 2021, one-third of physicians reported that such delays have caused at least one of their patients to experience a serious problem, such as hospitalization, the development of a birth defect, disability, and even death. The family had to remain in the hospital for at least two more days, Doraiswamy recalls, while the decision went through an appeals process.ĭoctors have long asserted that prior authorization-the need to get approval from the patient’s insurer before proceeding with treatment-causes delays that can hurt patient care. But there was a problem: The patient’s insurance company refused to authorize the new medication for the parents to administer. The child had fewer seizures, became more interactive, and was ready to go back home, says Doraiswamy. A hospital pediatrician, Vignesh Doraiswamy, consulted with neurologists and then tried a different drug. Last December, a young patient was admitted to Nationwide Children’s Hospital in Columbus, Ohio, after several medications had failed to quell the child’s relentless seizures. This story was originally published by Undark and is reproduced here as part of the Climate Desk collaboration.
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