Editor’s note: David Charles is a practicing neurologist and chief medical officer at the Alliance for Patient Access. The first draft of this piece was written by Amanda Conschafter, communications director of the Alliance for Patient Access, based upon David’s perspectives and experiences.
When I think of the many hours I’ve spent haggling with health insurers over the course of my 30-year medical career, I can’t help but wonder: How else could I have used that time? I could have caught up on current medical research articles. I could have mentored medical students and residents. Mostly, though, I could have spent more time with my patients.
Instead, my staff and I were calling, faxing and emailing an endless array of health plan forms and communications, all for what should be a simple task — getting my patients the medication or tests I prescribed.
The process is called prior authorization. Health plans require clinicians to get insurers’ permission for prescribed medications, procedures and tests. I can’t count the number of times when a patient and I have arrived at a diagnosis and defined our treatment plan, only to have it derailed when the insurer denies the prior authorization.
Because I treat people with movement disorders such as Parkinson’s disease, delays aren’t just inconvenient.
Neurodegenerative conditions worsen with each passing day. It’s tough to tell an older patient or caregiver who’s already struggling with a debilitating disease that coverage for their treatment has been denied. Working through the appeals process then adds yet another burden and delay for people already in delicate health.
And it’s not only my patients who face the prior authorization struggle.
I’ve met regularly with oncologists, rheumatologists, gastroenterologists, psychologists, cardiologists and other physicians for my work as chief medical officer of a national nonprofit called the Alliance for Patient Access. I’ve learned that when you put a group of clinicians in a room together, the conversation inevitably turns to one topic: prior authorization. Whatever their specialty area, clinicians see prior authorization growing more onerous, more common and more intrusive.
Trained, experienced clinicians who know their patients’ medical history are forced to ask permission from remote bureaucrats who have little knowledge of the treatment in question and still less of the patient. Yet insurers insist that prior authorization ensures “appropriateness of care.”
Beyond the inconvenience, however, prior authorization can have serious ramifications for patient access. Burnout rates among healthcare providers in the United States are soaring, and shortages have become a problem in more and more communities. Hassles like prior authorization can decrease job satisfaction, spurring more clinicians to leave the profession or retire early.
Prior authorization also bloats healthcare costs by increasing the administrative burden on clinicians and their staff. Many clinicians will tell you they’ve had to hire additional staff purely to handle insurance paperwork. Nearly two business days’ worth of a clinic’s time each week are consumed by it, according to a recent survey. That’s time and manpower that could be spent serving patients.
Patient health suffers too. A recent survey from the American Medical Association found that 93% of clinicians were delayed in providing care because they were awaiting prior authorization. And 34% said that, while waiting, their patient had a severe adverse event.
It’s welcome news, then, that potential reforms are on the horizon. A new rule introduced by the CMS, for example, would reduce burdens of prior authorization. If adopted, the new rule would streamline the paperwork filing process and institute standard response windows, requiring health plans to respond to requests promptly and to justify their requirements.
Another avenue for reform is Congress’ Improving Seniors’ Timely Access to Care Act. The federal legislation, originally introduced in 2022, would institute electronic authorization forms and real-time decisions for routinely approved requests for patients with Medicare Advantage plans. Legislators should seize the opportunity to reintroduce it this Congress.
Any healthcare provider can tell you that delaying patient care to protect health plan profits is a losing game. Patients, caregivers and clinicians like me are looking to thoughtful policymakers in Washington and beyond for a timely solution.
