When patients are suffering from life-threatening illnesses or debilitating health conditions, the only thing that should matter is delivering appropriate evidence-based treatments in a timely manner. For that, patients rightly turn to us -- their trusted physicians -- for expert guidance on the best course of action. Yet, all too often, insurers insert themselves into the equation. As a result, restrictive policies like prior authorization can interfere with patient care -- and lead to dangerous and painful outcomes.
As you likely know, prior authorization allows insurers to review doctors' orders and decide whether they will cover prescribed services. Such policies were initially established to help reduce healthcare costs by controlling patient access to more expensive or investigative medications, treatments, and therapies. But insurers have taken it too far -- overruling physicians' recommendations and defaulting to rejection of routine, evidence-based, and often life-saving care to prevent any expenditures.
Today, prior authorization has become one of the most widespread challenges in medicine, drastically impacting our two specialties: gastroenterology and rheumatology.
To fully understand what this means to our patients, consider a case of a patient at the practice I (Jung) am affiliated with who takes a biologic to manage her Crohn's disease. The patient typically suffers from breakthrough symptoms before her next infusion is due, so we asked for authorization from her insurer to increase her dose. Her insurance company required several letters to document and justify this change. This process resulted in a 1½-month delay before she could access the medication she needed to effectively manage her disease.
The patient is 44 years old and works as a gardener, so while she waited for prior authorization and continued to experience GI and musculoskeletal symptoms, her condition impacted her ability to perform her job and enjoy her life. That experience is the antithesis of patient-centered care. Yet, it's representative of all too many GI patient experiences nationwide.
Consider a case from my (Dyett Desir) rheumatology practice: that of a patient who suffers from systemic lupus erythematosus (SLE), the most common type of lupus. She is 62 years old and, after taking medication for 10 years, experienced flare-ups last summer that exacerbated her incurable rheumatic disease. Fearing the medication was no longer working, her rheumatologist switched her medication to an FDA-approved treatment, but her insurance company denied coverage because the patient did not have a specific antibody test result required by the insurer for that particular medication. The patient has to remain on a therapy that provides less-than-ideal benefits and is now enduring multiple rounds of glucocorticoid treatments to help mitigate her painful symptoms.
The state of play for prior authorization puts the insurer -- not the physician -- in the driver's seat for patient care, and that is wreaking havoc on patient safety and well-being.
Unfortunately, these examples are just a drop in the bucket of frustrating insurance barriers. According to a 2022 American Medical Association survey, virtually all physicians report prior authorization delays to access necessary care for their patients. Four out of five doctors report that the burdensome, lengthy prior authorization process sometimes or often leads to patients abandoning their doctor-prescribed treatment. Additionally, one-third of physicians reported that the process has led to a serious adverse health event for patients. Such events could include extreme pain caused by not being able to receive the right medication for rheumatic disease, or hospitalization due to a flare up of inflammatory bowel disease.
Relatedly, a recent Kaiser Family Foundation report found that approximately 60% of insured adults experience issues when using their insurance coverage. This includes 16% who faced problems with prior authorization -- particularly among Medicaid recipients, high-needs patients, those needing emergency services, and diabetes and mental health patients. These figures underscore the serious threat that prior authorization poses to patient outcomes.
That is particularly true for patients struggling with rheumatic diseases like arthritis, which is a leading cause of disability in the U.S., as well as a range of gastrointestinal diseases and conditions such as Crohn's disease, ulcerative colitis, and colon cancer -- the second most common cause of cancer death in the U.S. For these vulnerable patients, delaying or denying access to care often leads to disease progression.
Prior authorization should be used for what it was originally designed for: assessing insurance utilization in situations of statistical outliers, with the objective of decreasing unnecessary procedures, imaging, and treatments. True reform will support this goal, while reducing the scope of services, treatments, and medications that require prior authorization and increasing transparency between health insurers and physicians to minimize delays in care.
It is also critical to protect continuity of care by ensuring prior authorization does not interrupt a patient's course of treatment. Adopting an industry-wide standard for electronic prior authorization to improve transparency and increase efficiency must also be a goal.
In fact, CMS recently released a final rule intended to improve the electronic exchange of healthcare data and streamline processes related to prior authorization for government-sponsored healthcare programs. Last year, Congress came close to passing critical legislation to reform the prior authorization process that targeted Medicare Advantage beneficiaries after the House unanimously passed the Improving Seniors' Timely Access to Care Act. It's past time for legislators to revisit this issue.
Finally, commercial beneficiaries must be protected from big insurers who overstep their bounds with intrusive prior authorization policies with no data to support their rationale. When insurer policies turn into de facto medical decision-making for patients with commercial insurance or Medicare Advantage, there must be guardrails to protect the evidence-based care recommended by physicians and the health and well-being of our patients.
Barbara Jung, MD, is the president of the American Gastroenterological Association. Deborah Dyett Desir, MD, is president of the American College of Rheumatology.
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