3 takeaways from a cardiologist on prior authorization requirements

6.22.17

6.22.17

From patient assistance bans to limited networks and discriminatory drug cost sharing, medical insurance companies have created a wide variety of barriers to health care access for patients with chronic conditions.

One tactic receiving recent attention is prior authorization – a requirement from health insurers that forces patients to wait to find out whether treatment prescribed by their doctor will be approved or denied by their health plan.

Robert Shor, a past chair of the American College of Cardiology’s board of governors, recently published an article about this issue entitled “Prior Authorization: A Major Impediment for Patient Access” in Morning Consult.

“This approach to patient care is like walking a tightrope,” he said. “Efforts by physicians and nurses to ensure patient access to the most appropriate treatment can often be at odds with the financial interests of payers.”

Shor noted that several states, including Ohio and Delaware, have passed legislation to protect patients from overly burdensome prior authorization requirements.

Others should follow suit and enact these patient protections as well. Following are five major problems with prior authorization requirements.

1. Research has shown that prior authorization problems are common across the United States.

An American Medical Association survey found that:

  • 60 percent of physicians reported waiting an average of at least one business day for insurers to provide pre-approval for diagnostic, procedure or treatment, and 25 percent said they waited three days or longer to hear back about approval.
  • 50 percent of physicians experienced a 20 percent rejection rate on first-time prior authorization requests for pharmaceutical treatments, and one-third experienced a 20 percent rejection rate for first-time prior authorization requests for diagnostics and procedures such as cardiac stress tests and nuclear imaging.
  • 2. Prior authorization takes up physicians’ time, decreasing the time spent with patients and increasing health care costs.

    An American College of Cardiology study found that:

  • 77 percent of doctors spent less time on patient care because they instead had to deal with medical documentation involved in the prior authorization process.
  • 87 percent said they dealt with prior authorization issues on at least a weekly basis,.

  • 3. For patients with serious problems such as cardiovascular issues, the delay – or complete rejection – of treatment could mean death.

    “The insurance company will typically not even consider approving the medication if the patient hasn’t experienced (a heart) event,” Shor said.

    In other words, they can’t get the treatment prescribed by their doctor to prevent a heart attack because they haven’t already had one.

    If they fail to get their preventive treatment and have a heart event, they could die.

    Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led a coalition to call for changes in the health insurance industry.

    Representing hospitals, medical groups, patients, pharmacists and physicians, the group has proposed 21 principles for improvements to prior authorization programs.

    “Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” American Medical Association President Andrew W. Gurman said in an official statement. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

    Read more by clicking here.