Patients and Physicians Speak Out

Recently, [I] had back surgery and was discharged on medications for pain recommended by the neurosurgeon. They had to be prior authorized, and one was delayed so long that I did not even get it many days later when it was finally approved… I just had to grin and bear the pain. I am a primary care physician, and we are not exempt from the red tape created to enrich insurance companies that goes under the name of "prior authorization."

I’m a Type 1 diabetic. Although there is no cure for this disease, it can be managed with appropriate prescription medications and an insulin pump. I currently have to obtain prior authorizations for three of my medications…every single year. This year alone I spent at least 40 hours on the phone in connection with my prior authorizations. My insurance company is demanding that I work for it one week per year (i.e., 40 hours) to fight for the medications that my doctor and I know are in my best interest.

I use Dexcom G6 constant glucose monitor for controlling post pancreatectomy diabetes (I have half a pancreas). Getting sensor and transmitter refills for the G6 system is challenged each time by the supplier, Medicare and my secondary insurance. If I use the DME supplier, they request prior authorization, and sometimes refuse to send supplies out of schedule when I need them before traveling overseas. They shave the timing so close that often supplies are delivered late. If I pay cash out-of-pocket to get supplies more timely from the pharmacy it may take about 3 months to get $1,258 reimbursement and 2 to 3 hours of phone calls and emails with the pharmacy, Medicare, and [my health insurance] to get 3-months’ supply of sensors. [Prior authorization] is an unnerving, time-consuming process to be endured for the sake of keeping my diabetes in control and not becoming an even greater burden to the insurance companies as a result of secondary complications that result when the disease is not controlled. This does not make sense.

I have been taking a medication that truly keeps me alive for 5 years. The last time I went to get my script I was told I could not have it unless my doctor got prior authorization for that medication. I, of course, was low on that medication, picking my script up with a few pills left in my bottle. If my doctor had not given me samples, (it took over two weeks for the authorization to go through) I would have possibly been dead. After five years they decide I need prior authorization….

I have seen patients not able to get their Depo-Provera shots in time due to need for prior authorization and patients that have to wait for PA in order to schedule their required imaging, causing at least a 1-2-week delay. This is UNNECESSARY and frustrating when you think that the patient shouldn’t need to wait that long (seeing how if they were in the ER, they wouldn't have to wait, but rather you are going to punish the patient for going to their PCP instead?? BACKWARDS!!!). These are just the 2 examples from my last week in practice...and do not get me started on the amount of time (easily hours!) my staff spends EVERY week filling out prior authorization forms for medications, some of which are merely continuations of therapy medications for patients.

I work with a surgeon, treating breast cancer patients as the majority of our patients. I recently spent over 10 hours trying to get a patient's surgery authorized.