Patients and Physicians Speak Out

I represent multiple providers of different specialties. I have had it with the paperwork pushback from payors. Care is delayed and denied, and providers are made to jump through hoop after hoop just to treat patients. Starting with a reduction in prior authorizations is a step in the right direction. It's time for the AMA to truly start advocating for all the crap providers go through and put the payors in their place. Please fight to put providers back in charge of healthcare and NOT the payors.

I was approved for my medication and took it for 6 months. It lowered my blood pressure, A1C (hemoglobin) and hormones, and helped tremendously with my arthritis and joint pain. When it came time to renew my prior authorization, my insurance suddenly denied my doctor's request stating that they needed more records. These were provided and a peer-to-peer was done; however, they keep denying my doctor's appeals. 

Meanwhile, I’ve been without my medication for a month now. I can barely move from the pain from arthritis. I’m feeling a lot worse now and I cannot afford the out-of-pocket expense for my meds as I am the primary breadwinner, taking care of a 100% disabled veteran husband and our disabled daughter who has autism spectrum disorder.

Prior authorization for proper medical equipment and subsequent denials is what led to my mother's early demise and significantly lowered her quality of life. Now, I am also receiving similar prior authorization issues that are making it difficult for me to get medication. If you're on the same drug and the doctor increases the dose, why is there a prior authorization needed when they already have a prior authorization for the drug? This is absurd and is just an attempt to make it so difficult for the doctor, the pharmacy with excessive paperwork and the patient to get proper care.

I have Medicaid, and I was denied a medication with preauthorization from a doctor. I have had migraines for the past 30 years, and she gave me 75 milligrams of Nurtec ODT (rimegepant). You take one pill every other day to prevent migraines. When I was taking them, for the first time in 30 years, I didn’t have a migraine. 

I suffer from them [migraines] probably about 17 to 20 days a month. They make me sick, as in vomiting, and I actually have to go to a dark room to lie down. It hurts so bad, and it also makes my eyes blurry. I understand it isn't a cheap medication, but it actually works. You don't know how that feels – to suffer from migraines and not have any [medication]. Then your insurance company denies your medicine that you know works and you can't afford it. Just like the time when I had to take a thyroid medication, .075 micrograms of Levothyroxine, and was denied by Medicaid. Seriously. So, what, am I supposed to not just take my thyroid medication? Which I'm not because I can't afford $107.00 a month for it. But even with the Nurtec ODT, insurers are denying someone’s medication, which the doctor says helps tremendously and isn't a generic brand. I have taken everything else that Medicaid said I could have, and it didn’t work...

I've managed chronic, episodic migraines for 30 years. I've figured out tricks to complete work with a migraine when I wasn't able to take a sick day or reschedule something important and avoided narcotics. I worked through the pain, sometimes with a bandana tied tightly around my head, quietly slipped away to a bathroom to vomit, or gripped my desk so hard I broke off part of it. 

I usually end up in the ER 1 to 2 times per year due to breakthrough pain which medicine at home could not control after 8 to 14 hours. I visit headache specialists every 2 to 4 years to understand new options. I eat healthy, avoid alcohol, exercise and rest. Instead of it getting easier, preauthorization procedures have become repetitive busy work that ignores the fact that I and my care team are experts. 

My primary care doctor will no longer fill out the preauthorization paperwork, and I don't blame him. He does not have the staff to fill out inane paperwork or wait on hold to satisfy a checklist so CEOs can get a bonus of $20 million per year on a salary of $1.5 million. The 2 to 4 months wait for a specialist to have the same conversation over and over ignores my valuable time, which could be better spent using a medication that's been proven effective several times, vs. others that are less effective with more side effects which cause me to be unable to poop for days at a time... Caremark should know they're doing their part to keep health care complicated, expensive, ineffective and literally constipated, despite their claims to the contrary.

My mom recently experienced respiratory and heart failure, and she had to get a tracheostomy so that she can rely on a ventilator to breathe. After staying in ICU for two weeks, my mom’s care team determined that she was stable enough to be transferred to a long-term acute care (LTAC) facility so that she could be weaned off the ventilator. 

This is when our worst nightmare happened. Her Medicare Advantage plan from Aetna denied the prior authorization request for LTAC admission. They took five days to reach their decision, and they did not provide any sufficient explanation on why they denied the request. My mom’s ICU team was befuddled and wanted to speak with the clinical review team for a peer-to-peer conversation. Aetna said it was “too late” for a peer-to-peer conversation, and that the only recourse we had was to appeal. We appealed their decision, and it took them another five days to review our appeal, which they upheld. 

The whole process is convoluted and truly Kafkaesque. Aetna’s decision-making process is arbitrary and truly inhumane. What’s even more shocking is that my mom’s ICU team told me that they see this happen all the time, and that many patients in my mom’s situation just give up and pursue hospice care. 

Fortunately, we had the option to disenroll my mom from her Medicare Advantage plan and have her go back to traditional Medicare, which does not require prior authorizations for medically necessary services.