The AMA’s What Doctors Wish Patients Knew™ series gives doctors a platform to share what they want patients to understand about today’s healthcare headlines.
AMA President Jack Resneck Jr., MD, explains how prior authorization creates time-consuming burdens, making it difficult for patients to receive the care they need.
Voice off: We asked AMA President Dr. Jack Resneck Jr. to share how cost-control practices are delaying care and how patients can help the AMA fight prior authorization. When patients attempt to fill a prescription at a pharmacy, they are often told that their insurance company will not pay for the drugs unless their doctor gets approval. This tactic, used by insurance companies to control costs, is called pre-authorization. Here’s how Dr. Resneck explains it.
Insurance companies want to spend less. I think it’s largely an effort by health insurance companies to spend less money. What doctors are experiencing today and I know patients are finding the same when they come to the pharmacy trying to fill prescriptions is that it is now used for an incredibly wide variety of medications.
Prior authorization complicates decision-making. That means when we’re sitting together as a team, a doctor and a patient, working out what’s going to be the best next steps in diagnosing and treating that patient’s condition, there’s this whole other part of what needs to have takes place during this interaction of the doctor trying to predict what treatments he will actually be able to get for this patient, even if this patient has health insurance.
Fighting rejection takes time. Many of us have people in our offices, staff, who are just focused on filling out pre-clearance paperwork. In my own office, we have to rotate this among the staff because it’s such a heavy job that no one could really do it all day. So it really diverts resources in addition to delaying really important care that patients need.
Barriers to prior authorization are harmful. As doctors, we often find ourselves fighting over and over again through a series of calls to get the patient to get the medicine, test or treatment they need. If you stick with it and are willing to fight repeatedly, I find that doctors can often win the battle. And in a way, the percentage of times we do that being so high is proof that the health plan didn’t need to put those barriers in place in the first place because doctors prescribe appropriate treatments based on evidence, and the health insurer ends up recognizing it. But in the meantime, the patients are not treated.
Previously covered services may change. The other thing we run into is a continuity of care issue, where patients find a drug that works for their condition, for their chronic disease, and they take it, and they’re fine. And then, all of a sudden, a year later, we get a note from the insurance company that says – hey, your refill has triggered another pre-authorization requirement. So, one of those repeated previous authentications fired. I dutifully filled out pages of paperwork to explain to the insurance company that the patient was doing very well and that his illness had really improved with the medication. I received a refusal.
Efforts to secure prior authorization are underway. We’re starting to see some states that have taken steps to limit the number of things that may require prior authorization to try to address continuity of care issues, where patients are being inappropriately removed from medications they’re stable on. We gave the health plans a few years, we worked with them, but unfortunately the health plans did not follow through on those promises. And we see patients really still suffering.
Share your stories: If we’re going to be successful in convincing Congress and state legislatures and others to step in and fix this problem, they need to hear, not only from the doctors, and we’re talking loud and clear, but they need to hear you too as patients.
Voice off: From high cholesterol to sleep apnea and long COVID, find out what doctors want patients to know about today’s healthcare headlines at ama-assn.org/wish.