Death by Prior Authorization

April 24, 2019

Pharmaceutical Executive

Health plans should pause in calling for prescription prior authorizations or answer the call for process reform to ensure effective patient care.

I recently read news that really brought home the real-life impact on patient care -really, on patient’s lives-of an effective prior authorization (PA) process. In February 2019, long-time disability rights activist and attorney Carrie Ann Lucas1died prematurely at age 47 from a plethora of health problems, exacerbated by her disabilities.

However, according to a post following her passing on her Facebook page, her friends and family identify the root cause as the denial by her insurance carrier of “the one specific inhaled antibiotic that she really needed. She had to take a less effective drug and had a bad reaction to that drug. This created a cascade of problems, loss of function (including her speech).

This story highlights three important issues:

First, it is a fundamental truth of effective patient care that providers choose the medication that they think is best for treating their patient’s condition-and that much of the time, substitute drugs are thought to be less appropriate. In the case of the medication prescribed to Ms. Lucas, that less effective drug was the beginning of an unstoppable downward turn in the patient’s already precarious health.

Second, in spite of this truth, physicians often concede to health plans when a prescribed medication is denied, rather than navigating the burdensome process of submitting a prior authorization. I make this assertion based on conversations my team has had with hundreds of physicians and their staff, from which discussions I can also assert that the term “burdensome” is not an exaggeration.  Just consider the results of a survey the American Medical Association (AMA) issued in 20172, in which they found that:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.

  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.

  • Nearly 60% of surveyed physicians reported that their practices wait, on average, at least one business day for prior authorization decisions-and more than 25% of physicians said they wait three business days or longer.

  • Nearly 90% of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

Third, according to the account of Ms. Lucas’ case, while the health plan thought they were saving $2,000 by denying the originally prescribed medication, they ultimately spent over $1 million on care for the patient as a result of the complications. Per the aforementioned post by Ms. Lucas’ family-which is worth noting includes her wife, who is herself a physician specializing in family medicine, until a progressive neurologic illness forced her to leave practice-  “[post-denial] health care costs over the past year... includes numerous hospitalizations, always involving the Intensive Care Unit which is par for the course for ventilator users.”

Although tragedies such as Ms. Lucas’ should give plans pause in calling for prescription prior authorizations, or at the least, answer the call for process reform from the AMA and other organizations, the reality is that the volume and complexity of PAs is only increasing. It is up to physician practices to find a better way of navigating the PA process. This is why my team created the PARx Prior Authorization Support System (PASS)- a prescription prior authorization platform, free to physician practices, that streamlines the submission process. In addition to saving staff members hours and stress, PASS ensures accuracy and timeliness and by so doing, increases the opportunity for approval.

For every PA that we process, our goal is to help the patient receive the medication prescribed by her physician. In the case of Ms. Lucas, that simple action-obtaining approval of a prior authorization-might have added years to her life.

 

Dan Rubin is president and CEO of PARx Solutions.

 

1https://en.wikipedia.org/wiki/Carrie_Ann_Lucas

2 https://www.ama-assn.org/press-center/press-releases/health-care-coalition-calls-prior-authorization-reform