Across the country, patients are experiencing delays in care that can have life-threatening consequences. And the worst part? Insurers are driving this delay, hurting patients and hand-cuffing doctors.
These horror stories are all too familiar for us treating patients, and they are becoming increasingly common. Patients who need a certain medication or specific test to try to prevent or diagnose life-changing or life-threatening illness are often unable to do so in a timely manner. In the worst-case scenarios, patients die from something that may have been preventable.
Delays like this come from an extra step in the insurance approval process called "prior authorization," where a health care plan needs to approve a medicine or therapy before a patient receives it. This is different from the normal way that a doctor prescribes a medicine to a patient when the patient simply picks the medicine up at the pharmacy. If it turns out that the insurer requires a prior authorization, doctors often must go through a long process that requires filling out extensive paperwork, faxing it to insurers, making multiple phone calls, and spending increasing amount of time talking with insurers instead of patients.
The process for approval commonly lasts several days to weeks, and it is not without negative consequences. A 2021 survey by the American Medical Association found that 93 percent of physicians reported that prior authorization can delay access to necessary care. More than1 in 3 physicians report that prior authorization led to a serious negative health event for their patients, including death.
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Ultimately, we need to ask ourselves: do we really want health insurers to be the gatekeepers of health care treatments decided between patients and their doctors?
The majority of doctors have become so frustrated with the delays that they abandon their planned therapy. These changes to treatment delay our care for time-sensitive medical issues and may require changes to other parts of our patients’ lives, like their diet. The delay may also make patients sick – or even die.
And does all this back and forth with insurers ultimately change what the insurer will approve anyway? No. Most medications needing a prior authorization are ultimately approved.
Prior authorization not only hurts patients, but it hurts doctors and the art of medicine, too. Instead of spending time treating patients, physicians and their staffs are spending almost two full days a week working on prior authorizations. The time has gotten so extreme that 40 percent of physicians have staff that work exclusively on prior authorizations. This has gotten worse in recent years as prior authorizations have become increasingly common. At a time when we as doctors should be spending time with patients, we are somewhere else doing paperwork for insurers—a bureaucratic burden that worsens physician burnout. Not only does physician burnout lead to poor patient care and high numbers of physicians leaving the profession, it also has the devastating effect of increasing physician suicide.
Despite the obvious harm to patients and physicians, many defend prior authorization as a way to save money by preventing physicians from prescribing medicine or service that can be expensive. By requiring prior authorization, supporters argue, insurers can direct physicians and other prescribers towards less expensive medicines. This view is short-sighted. These "cost savings" often come from comparing a more expensive medication to a less expensive alternative medication, but they do not capture the overall increased cost that comes from patients who become sick and require other expensive treatments or hospitalization because they are waiting for the results of a prior authorization or the burnout and mental health toll on physicians.
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To address these challenges, Congress must act to reform our current prior authorization system. It can start with modernizing prior authorization in Medicare Advantage to provide better care for seniors. We should move away from a prior authorization system where forms are done by hand and then faxed to insurers and move towards an electronic one where the process is streamlined, especially for commonly approved medications and services. This could save both money and time. In addition, prior authorization decisions should be made quickly, and all efforts should be made to protect patients from disruptions in their care.
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Congress can act during this session. U.S. Senator Dr. Roger Marshall’s Improving Seniors’ Timely Access to Care Act of 2021 is a bipartisan, bicameral bill with support in both chambers of Congress that would achieve these goals. By passing this legislation, Congress can send President Joe Biden a bill that creates a health system that is more efficient, less expensive, and focused on getting patients the care they need. His signature on this legislation would send a welcome message of support to patients and health care professionals. By taking these steps, we can move away from an outdated system that delays patient care and contributes to physician burnout. The lives of our nation’s patients and doctors may depend on it.
David N. Bernstein, MD, MBA, MEI is a resident physician at the Harvard Combined Orthopaedic Residency Program at Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, and Boston Children’s Hospital.