Prior Authorizations: The Good, the Bad, and the Ugly

Prior authorizations (PA)—I cringe even as I type the words. As I sat at my desk recently, staring at a mound of PAs that required attention for common medications such as clobetasol, I began to question how we got to a place in health care where insurance companies dictated our every move, and a large part of our jobs turned administrative. Do we even understand what purpose a PA serves? Did any practicing physicians have an opportunity to weigh in on the potential benefit vs detriment that may impact our prescribers and patients?

According to the Academy of Managed Care Pharmacy (AMCP), a PA is an “essential tool” in optimizing patient outcomes by ensuring that members receive a medication that is “safe, effective, and is of the best value.” As we are all aware, a PA requires a prescriber to get approval for coverage prior to a member obtaining the medication that the prescriber deemed best fit for a certain condition. According to the AMCP, guidelines are determined by pharmacists and “other qualified healthcare professionals.” In addition, PA programs are apparently designed and utilized to consider the workflow impact on prescribers and “minimize inconvenience” for health care providers and patients.1
I am not the only provider who feels that a PA serves to negate the goals listed above. According to a recent survey of 1000 physicians conducted by the American Medical Association (AMA), 92% found that PAs have a negative impact on clinical outcomes. Almost all of the responders reported extreme delays in necessary care, and most physicians reported that a PA lead to complete treatment abandonment, thus leaving patients without any appropriate care.2 I wonder if these committees have considered the negative impact of not treating patients. I am concerned that a patient who does not obtain appropriate care may then end up with more comorbidities and negative outcomes, which can increase costs at a later date. Unfortunately, only “qualified healthcare professionals” seem to be able to weigh-in on such topics.

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What are the positive implications of PAs? According to a report released by the Government Accountability Office, Medicare PA programs saved Medicare anywhere from approximately $1.1 billion to $1.9 billion from 2012 through 2017.3 What is the impact of these “savings”? I have observed costs shift from the government and insurance companies to providers and patients. Not only is physician reimbursement continuously dropping, but billable hours are on the rise and creating a constant increase in overhead. As a physician with a high population of patients with psoriasis, I am spending money on additional staff to fight for the care my patients deserve. Many dermatologists are so overwhelmed and burdened by the system that they do not offer the appropriate medications for patients with this complicated disease. In a system where we are constantly bogged down by entitlement, payment refusals, Merit-based Incentive Payment System /Medicare Access and CHIP Reauthorization Act, and other government regulations, we are handicapped by the system.

Physicians’ finances are not the only aspect that is affected. Patients are also seeing a rise in their out-of-pocket costs, such as increases in deductibles and premiums. Insurance accumulators have stopped allowing patients to use copay cards to decrease their deductibles and out-of-pocket expenses. Many of my patients are stopping their life-altering biologic medication until their deductibles have been met, and sometimes never reinitiate secondary treatment due to cost. I have seen where this leads to an increased rate of hopelessness and depression, and many of my patients are now left in their high-inflammatory state, coupled with many comorbidities, without the treatment they need.

There is something we can do—advocate! If we allow the payers to cut corners and inhibit patient care, they will continue to do so. As time consuming as it is, make the time to do peer-to-peer reviews. Find out how to get on your local payer’s committees and fight to decrease step-edits for the medications that are important to you and your patients. Provide supporting research articles to your patients and encourage them to advocate for themselves. At the end of the day, payers need us in order to attract members. We need to recognize that we have power and work to take it back.

Visit aad.org/priorauth for assistance and information from the American Academy of Dermatology to help reduce the PA burden on your practice and also ama-assn.org/prior-auth for information on the AMA’s advocacy efforts and resources to reduce PA burdens.2

Dr Hawley is a board-certified dermatologist and an associate clinical professor at Michigan State University in Grand Rapids, MI.

References:

  1. Academy of Managed Care Pharmacy. Prior Authorizations. April 2012.http://amcp.org/prior_authorization/. Accessed March 20, 2019.
  2. America Medical Association. 2018 AMA prior authorization (PA) physician survey.https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Accessed March 20, 2019.
  3. US Government Accountability Office. CMS should take actions to continue prior authorization efforts to reduce spending.https://www.gao.gov/products/GAO-18-341. Published April 20, 2018. Accessed March 20, 2019.