By Daniel Skubick
Last year, Pennsylvania became one of the first states in the U.S. to remove a significant barrier to patients suffering from opioid use disorder. Gov. Tom Wolf struck a deal with every major insurer to remove “prior authorization” as a requirement for medication-assisted treatment.
It begs the question: if insurers recognized prior auth as a barrier to treat opioid addiction, why have they been so slow to reform the prior authorization process in other areas of health care?
Health insurers began using prior authorization decades ago as a cost control method. Before physicians can prescribe certain medications, tests, or treatment plans for their patients, they must first contact each patient’s insurance plan for prior authorization.
Its use in some areas is justified. But as a practicing neurologist with 40-plus years of experience, I’ve seen this system grow out of control and inflict unnecessary pain on patients.
One of the more extreme examples came a few years ago when I was helping a patient taper off opioids.
In this case, my patient had just undergone his fourth back surgery in five years and was taking pain medication to aid with recovery. Things were progressing well enough for him to begin taking a smaller dose of the medication – a process known as tapering that would eventually allow him to wean off opioids altogether.
However, his insurance company denied payment of the lower dosage that I had prescribed. After numerous appeals, the lower dosage was eventually approved. But delays meant my patient had to go without the medication for several days and he began experiencing withdrawal symptoms.
One could imagine a reason for denying approval of this medication if we were increasing it. But in this case, we were following a best practice to ensure he did not overuse and fall into addiction.
In spite of the fact that we were doing the right thing – safely getting him off opioids – the insurance company’s prior authorization process proved to be a barrier and inflicted needless pain.
We were never given a clear answer as to why his medication decrease required a prior authorization. You could talk to two different people at the insurance company and get two different answers. This, to me, is another example of an inefficient process that delays care and hurts patients.
Many of my physician colleagues in Pennsylvania and around the nation say the same thing. More than one out of four physicians in a nationwide survey by the American Medical Association say prior authorization has led to a serious adverse event for at least one of their patients.
At the very least, insurers should modernize this system. According to Modern Healthcare, 88 percent of prior authorizations are conducted either partially or entirely manually, often by phone or fax.
Pennsylvania state Rep. Steven Mentzer, R-Lancaster, and Sen. Kristin Phillips-Hill, R-York, have introduced companion House and Senate bills that aim to decrease patient wait times by streamlining and standardizing the prior authorization process while increasing transparency from insurance companies.
The Pennsylvania Medical Society and the American Cancer Society Cancer Action Network are among the dozens of health care and patient groups supporting these bills.
Our medical decisions should be made by patients and physicians. House Bill 1194 and Senate Bill 920 could prevent others from enduring unnecessary treatment delays and pain.
Daniel Skubick, MD, is a neurologist who practices in North Wales, Montgomery County, Pa. He wrote this piece on behalf of the Pennsylvania Medical Society.
Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. Please see our republishing guidelines for use of photos and graphics.