Patients and Physicians Speak Out

On top of having to live with chronic pain, my patient had to endure acute pain without additional pharmacological support because Medicare wouldn't approve the appropriate (and safe) pain prescription. The patient cared for himself and used his street connections to (unsafely) treat his pain.

As a country, we take pride in medical innovation. We say that the value of our system is the new procedures or medications we create. But I don’t think I’ve ever successfully prescribed these medications to the patients who need them. I’m early in my career and every time I’ve tried, I’ve encountered paperwork like prior authorizations. As a new physician, this can be a nearly unsurmountable barrier. No one teaches you how to complete these forms. This is a major barrier to care for my patients, and a major disservice to medicine as a whole because it prevents us from progressing. When we can’t use the medications that we have available, we’re letting our patients down and wasting the resources we have available.

I’ve wanted to be a primary care doctor for as long as I can remember. The reason being, I didn’t feel like my family had a quarterback who was directing our care, preventing illnesses we didn’t see coming and mitigating the burdens of diseases that already were at work. The single most frustrating issue I have faced as a primary care physician, that constantly makes me second guess my dreams, is the [prior authorization] PA issue. I have young children with type 2 diabetes who have made so many healthy changes but have to keep taking insulin daily because they can’t get a once-weekly medication. I have reproductive aged women who worry about their fertility and future health because they are not able to lose weight and I can’t offer them an evidence-based, FDA-approved medication to assist them because Medicaid has just made access to GLP-1’s [glucagon-like peptide-1] for a weight loss indication non-negotiable. I feel helpless. I feel like I can’t do what I was trained to do because of the insurmountable, unnecessary barriers PA’s pose. Please help me help my patients. These medications will save money in the future by reducing the costs of heart failure admissions, necrotic diabetic foot admissions & ICU admissions for hypertensive emergency. Trust me.

I am a resident physician in Baltimore who takes care of adults and children. I wrote a prescription for a patient upon discharge to continue two important medicines that were started by an inpatient specialist while he was admitted to the hospital for over two months. I received two prior authorizations for these medicines requesting additional documentation for these medicines that he had been on for at least a month. This delayed him getting these medicines refilled, causing his parents to stretch the quantity of medicine they had and give him less than he needed. He was finally able to get the medicines after multiple physicians and other staff worked on it for over multiple hours. The system needs to be changed to allow patients to get timely and necessary care.

We found out our son has asthma after two frightening trips to the emergency room (ER}, followed by days in the hospital when he was four years old. The doctors prescribed Flovent as a maintenance treatment to help keep his airway clear and prevent return trips to the ER when he would get an illness. The first time I tried to pick up this medication I heard of “prior authorization.” I thought, “What does this mean?” The doctor prescribed it, so why does an insurance company get to decide whether it’s required? Luckily, the doctor was able to get it approved quickly. The next time I tried to pick it up, it was the same - why would they need to approve it again for the very same medication? This time, I ended up paying out of pocket because I needed it that day to continue treatment. Over the past two years, he’s been using this [medication] and I’ve been held up at least half a dozen times for prior authorization for the same medicine for the same ailment - it has not changed!! Why does it have to continually get approved? With the new plan year, we may have to move to a different medicine, which is incredibly unfortunate for a young child to have to switch from something that is working to an unknown.

I am currently dealing with a rescinded approval that my insurance company sent me in writing that gave prior authorization for the one medication that provides better quality of life. They had no issues covering it until January 2025 after over four years of paying for my monthly prescription. I am a Medicaid, Medicare patient. On Thursday, they [insurers] sent me another letter denying and taking back the approval, plus they gave me a window of 72 hours in which to appeal. My doctor's office is not available on Friday, Saturday or Sunday, so I don't know what or how to proceed. This is extremely stressful and causes great duress. How can it be legal to approve and deny in writing within a few days?