Patients and Physicians Speak Out

A court determined that my patient's antipsychotic medication was necessary for preventing life-threatening behavior. The patient's family told me that they couldn't afford the medication without [prior authorization] through insurance. Insurance would not give me an option that met the patient's needs fast enough to reduce the risk of life-threatening behavior. It's a bit disappointing that the word "life-threatening," coming from the prescribing physician, isn't enough to move the ball when working with these insurance companies [on prior authorizations]. After hours on the phone with the insurance and pharmacy, well after business hours, our best option was to use an un-tested medication and a GoodRx coupon. I did not sleep well that night.

Sometimes [prior authorization] INCREASES the cost of care, which it is intended to combat. For example, certain higher level imaging studies are needed, no matter what, to evaluate for a condition. Carriers have blanket requirements that lower-level imaging be performed first, and in certain cases, this lower-level imaging will not help at all- it will not change the fact that the higher-level imaging is necessary. So, insurers are REQUIRING that we order two studies instead of one. The alternative is to send a patient through the ER, which is clearly not cost-effective for a condition [that] can be managed at the outpatient level. This is unnecessary, wasteful, and contributes to increased costs for all. All of this AND calling to do a "peer-to-peer" discussion has no impact: the "peer" can't waive the lower-level imaging requirement even when they medically agree, and it takes up at least 30 minutes of time, which would easily be 1-2 more patient visits.

One of my patients is an uncontrolled diabetic with an HbA1c>11%. She was started on insulin. She was able to get the insulin but was unable to use it because she needed a [prior authorization] for the insulin needles! This is ridiculous and extremely dangerous for the patients! -Mariam S., MD, VA

I am a pain management specialist, so nearly every one of my patients is on high-dose opioids. Nearly every single script I write requires prior authorization - even for what I would consider "reasonable" levels of chronic opioids (based on the patients I see, at least- NOT on what a PCP might encounter). Clearly, some of the problem is from the overly restrictive policies that have superseded physician judgment with "protocols and guidelines." Those protocols and guidelines have been created to address 90-95% of the patients that are seen in the normal course of routine practice.... yet nearly EVERY one of "my" patients falls into the 5-10% range of patients that are "outliers" due to their need for high-dose opioids.... which is the whole reason that they were referred to me in the first place.

For patients on high-dose opioids, having to wait for a prior authorization or a "discussion” ("fight") with a pharmacist, can risk putting them into acute opioid withdrawal. However, it also means that I routinely have to spend 30-60 minutes "above and beyond" the actual time spent with the patient and time spent charting. My only recourse is to now document all of that time in detail and "code accordingly," meaning that I am trying to get reimbursed for the additional time spent doing these prior authorizations. Although this is costing the insurance company a marginally increased amount of money, the amount generally does not adequately compensate me for my time and frustration. It greatly increases the patients' anxiety, as well. For "specialists," there really should be no excuse to demand additional paperwork [that] appears to be nothing but perfunctory.

As a prescriber for children, I found the [prior authorization] system immoral. It caused delays in treatment for my kids with ADHD, severe anxiety and mood disorders, and PTSD. I always wrote in the comments space: “Congratulations! Once again you have - for no clinical reason - successfully interrupted and delayed essential treatment for my patient.”

I am constantly receiving automatic [prior authorization] denials for necessary medicines for my multiple sclerosis (MS) patients, with insurers denying [prescriptions] outright, or insisting I use their preferred and often inappropriate or less effective agents…and even refusing to approve routine imaging studies. Can spend hours trying to get through to a peer for discussion - am told that the call will be returned, and it never happens.