Prior Authorization: A Major Impediment for Patient Access

Imagine your doctor recommending a diagnostic test, medical procedure or pharmaceutical treatment that could improve your condition or even save your life. Next, imagine being told that you first had to wait one to three days for approval from your insurance company and/or that you couldn’t receive that treatment at all because they wouldn’t cover it.

Unfortunately, this is common for patients across the country. Per a survey by the American Medical Association, nearly 60 percent of physicians say their practices wait an average of at least one business day for insurers to provide pre-approval for a diagnostic, procedure or treatment, while more than 25 percent say they wait at least three business days. Additionally, the survey showed that more than 50 percent of physicians experience a 20 percent rejection rate from insurers on first-time prior authorization requests for pharmaceutical treatments, while more than one-third experienced a 20 percent rejection rate on first-time prior authorization requests for diagnostics and procedures.

As a cardiologist, I have patients with heart disease, many who have already experienced a cardiovascular event and despite all efforts, they are on the maximum tolerated dose of a statin, but their cholesterol levels are still too high. Often, we’ve tried four or five different statins and they simply do not respond or even worse, they experience adverse reactions. Recently, a new class of drugs has been introduced to treat cardiovascular disease, but I’ve seen barriers to providing these therapies for my patients create an ongoing challenge. For example, some insurance companies require a patient be on a statin, despite documented intolerance, before they will consider approving them for a new treatment, such as a PCSK9 inhibitor. This creates a challenge because instead of getting my patient the treatment they need, I enter into a time-consuming process to obtain payer approval, which doesn’t always happen despite my best efforts. The process becomes even more challenging and frustrating when treating my patients with heart disease who have yet to experience an event, such as a heart attack. The insurance company will typically not even consider approving the medication if the patient hasn’t experienced an event.

This type of approach to patient care is like walking on a tightrope. Efforts by physicians and nurses to ensure patient access to the most appropriate treatment can often be at odds with the financial interests of payers and their stakeholders. There are countless stories of patients being denied nuclear imaging procedures, cardiac stress tests, cardiac catheterization procedures, and/or other imaging procedures and ultimately being admitted to the hospital for emergency surgery. In a recent survey by the American College of Cardiology, 77 percent of respondents noted less time was spent on patient care due to the time required for medical documentation and the prior authorization process. Additionally, 87 percent of respondents said they address prior authorization issues at least once a week, with 74 percent noting they can spend up to 60 minutes addressing each request.

The field of medicine demands changes to prior authorization requirements. A coalition led by the AMA, including the ACC as well as a broad range of health care industry stakeholders have developed a set of principles that would allow patients easier access to certain treatments recommended by their health care providers. This coalition is centered around ensuring any requirements are clinically valid and evidence-based; maintain continuity of care; are transparent and fair; allow patients timely and efficient access to drugs and treatments; and clearly articulate alternatives and exemptions. The need for standardized processes is an important element and would help ease the burdens on physicians and practices, who must navigate varying processes to get patients the care they need.

Several states, including Ohio and Delaware, have already passed legislation to protect patients from overly burdensome requirements. In Ohio, insurers must now disclose all prior authorization rules to providers and enrollees of the health plan must receive basic information about which drugs and services will require prior authorization. The law also requires faster time frames for prior authorization decisions for urgent/non-urgent situations and prohibits retroactive denials regarding coverage or medical necessity if the procedure was performed within 60 days of receiving authorization. Laws like this could provide a blueprint for other states looking to make prior authorization more transparent and patient-centered.

While clear strides have been made in affecting meaningful change in this process, much work remains in finding a solution that meets the needs of patients, providers and insurers. Walking a tightrope is a challenge, but it’s also invigorating to see what you’ve accomplished once you get to the other side. Insurers, health care providers and lawmakers need to work together — one step at a time — to find a solution that at the end of the day saves time, money and, most importantly, lives.


Robert Shor is a partner at Virginia Heart and is a past chair of the American College of Cardiology’s Board of Governors.

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