Time to reform the prior authorization process of health insurance companies

Take cancer patients. A 2019 survey found that 93 percent of oncologists experienced unnecessary delays in life-saving cancer treatments due to prior authorizations. A study conducted by the Cleveland Clinic found that mortality rates increased between 1.2 and 3.2 percent for every week that the initiation of treatment was delayed.

The American Society for Radiation Oncology recently interviewed several oncologists on the issue and quoted it: “In some situations, (for) patients with severe acute problems such as obstructive tumors, painful tumors, the rapid review still is multiple days. Certainly, this can lead to patients not overcoming a severe situation and dying from it.”

“It is not right,” the oncologist added. “It is inhumane.”

Now, driven by the course of the COVID-19 crisis, temporary reform of the prior authorization process is emerging. But the question arises: can reform be made permanent?

The growing scope of the problem is well documented. In a poll of 1,000 physician practices conducted by the American Medical Association in 2018, 28 percent reported that prior authorizations had resulted in cases of serious adverse events for patients. These include hospitalizations, permanent bodily damage, or death. In addition, 91 percent said that prior authorizations harmed patients’ clinical outcomes. And 21 percent said their patients often abandoned their treatment as a result of prior authorizations.

Further, one-third of doctors’ offices have had to hire people solely to deal with the administrative burden brought on by prior authorizations.  

The appearance of COVID-19 made matters far worse. While it is too early to have good statistics on the phenomenon, physicians have reported additional and widespread delays. The National College of Physicians has written that patients awaiting prior authorization approval for discharge have experienced delays ranging from four days to two weeks. The result has been patients unnecessarily occupying hospital beds that could have been used for COVID-19 patients during this emergency.  

My company’s experiences, which provide support services to patients who need specialty medications, have taught me that the prior authorization process is a bureaucratic obstacle course in the best of times. And these are not the best of times.  

The prior authorization process is a lengthy one, in which denials and appeals are often repeated several times for each patient. As one nurse told me: “the insurance company fights to deny, we fight for approval, and whoever is left standing at the end of the process wins.”   

In recent weeks, the states have taken action to protect patients and physicians from the harm and waste associated with prior authorization during this crisis. More than forty states have temporarily suspended prior authorization requirements for fee-for-service Medicaid, the government insurance program for the poor. Other states have removed prior authorizations for COVID-19 testing and treatment. California and New York have gone even further.   

The health insurance industry has responded, in some cases, wisely, in other cases, grudgingly. Humana, admirably, has suspended prior authorizations for patients seeing in-network providers. Other insurers have temporarily removed prior authorizations for COVID-19 testing, treatment, and transfers from hospitals to acute care facilities.  

While we have seen some progress, it is by no means enough.  

First and foremost, the states should suspend all insurance companies’ prior authorization programs for the pandemic duration. But after the pandemic subsides, it does not make sense to return to the status quo.  

In imposing prior authorizations, insurers must allow physicians with good track records to prescribe drugs or procedures without going through the authorization ordeal. Physicians who regularly score well on quality performance measures and adhere to evidence-based medicine practices should be exempt. Also, insurance companies can do a better job of regularly reviewing and reducing the number of therapies that require prior authorization. 

In addition, insurance companies need to invest in the simplification of the authorization process to make it fast and transparent. Insurance companies will argue that without strict prior authorizations, they cannot prevent unneeded treatments and unnecessary costs to the system.  

But the costs of prior authorizations — from the impact on patients’ health to a vastly increased administrative burden for physicians — was reaching a breaking point even before the dawn of the pandemic. Now is the time for permanent reform. 

Vincent J. Rogusky is the executive chairman of Occam Health, a patient support services company that assists patients on behalf of pharmaceutical manufacturers.