This is a question we get a lot in the office, and if you’re frustrated, it might help a little to know that you’re not alone. In fact, prior authorizations have become such a burden on patients and physicians that the American Medical Association has identified fixing the prior authorization system as a top priority. The good news is that there is something you can do.
What is a prior authorization?
Prior authorization is a cost saving mechanism that insurance companies use to limit access to certain medications by creating arbitrary requirements that physicians must submit to justify the use of those medications. While initially limited to newer, expensive drugs, the process was so successful at cutting insurance company costs that it has been expanded to encompass medications that are prescribed daily and have been around for decades. The prior authorization process exists only to cut costs by creating a barrier to use certain medications. It is not based on the quality of care, medical science, or a patient’s best interest.
Prior authorizations are arbitrary, unpredictable, and interfere with the doctor-patient relationship.
Because of the number of different health plans and the arbitrary nature of prior authorizations, your physician likely has no idea what medication any particular patient’s health insurance plan will cover, and which will require a prior authorization. Even once the physician becomes aware that a prior authorization is required, we often have no way of knowing what criteria the insurance company has set in order for the patient to be approved for that particular medication.
Not only do prior authorizations delay patient treatment, but they often require changing a patient’s prescription to a medication that had not been discussed during their clinic visit. Insurance formularies and prior authorization criteria can change year to year as well, and patients may be forced to change medications even if they have chronic conditions that have been stable for years on a certain drug.
The prior authorization process wastes valuable staff time
The average physician in the US across all specialties receives 41 prior authorization requests per week. Most offices have dedicated staff whose only job is to perform this task, filling out paperwork, faxing documents, and working through telephone menus. These mundane tasks contribute to higher overall health care costs and are also a source of worker dissatisfaction and burnout. It is certainly a job dreaded by our staff.
Prior authorizations can be harmful
Delaying health care puts a patient at risk for bad outcomes. If you can’t treat your condition in a timely manner, things will likely get worse. Even more concerning, however, is the fact that up to 1/3 of patients whose prescriptions get stuck in the prior authorization process don’t ever receive their medication.
Everyone is frustrated by the prior authorization process
Physicians just want to provide effective therapy for their patients. We have taken on a significant administrative burden to try and accomplish this goal. Delays and excessive costs can be very frustrating to patients, and the complexity and lack of transparency of the prior authorization system often paints the medical offices as the cause of the delay. Our staff regularly endures the ire of frustrated patients when we are just as aggravated as they are, and attempting to navigate a purposefully complex and confusing process on their behalf.
Take action to help remove the prior authorization process
Several years ago, the American Medical Association created a consensus statement on things that could be done by insurers to rectify these problems, but no action has been taken. Now there is a push for Congress and state legislatures to act on protecting patient access to care. Lawmakers, policymakers, and health care companies need to know about the pain that you are facing as patients and how it is adversely affecting your health care. The AMA has created a website, FixPriorAuth.org for patients to share their experiences. We will continue to work diligently on your behalf to navigate this unnecessary system, but we encourage our patients to speak up if they are negatively impacted by the process.