REQUEST DENIED
Patients, physicians voice frustration with insurers’ prior authorization demands
John Emerson still wonders if his previous insurer’s hesitance to approve an MRI means his shoulder will never heal entirely.
He’s also irritated that his family’s current insurance plan forces his wife, Christine, to take a daily 60-milligram capsule for anxiety that makes her nauseous, instead of one 30-milligram capsule twice a day.
“I have discovered that doctors are really no longer permitted to be doctors,” he wrote to the Pittsburgh Post-Gazette recently. “They can no longer treat nor prescribe medications unless the insurance companies say they can.”
The issue, says the 54-year-old construction manager, is prior authorization — the requirement that plan members get their insurer’s OK for medical treatment ahead of time.
An article in the Medical Economics trade publication that reviewed histories of four major insurers found typically fewer than 10 percent of claims required prior authorization in 2013 — but those percentages were growing. In one case, the insurer history showed an increase from 1.7 percent of claims in 2011 to 7.3 percent two years later. With another, the rate went from 4.9 percent to 12.4 percent.
Only one of the insurers saw a decrease — from 6.2 percent of claims to 4.7 percent. And in 2015, American Medical Association researchers cited industry estimates that drug prior approvals will increase 20 percent per year.
Now, a growing number of organizations are questioning this system’s impact on care and patients’ lives even as the industry looks for ways to cut into the nearly $3.5 trillion spent annually on health care in the U.S.
Take, for example, how prior authorization has impacted this Indiana County resident’s life:
Mr. Emerson, 54, fell two years ago, landing on his left elbow and injuring his shoulder. “I could tell right away there’s something wrong in there.”
He told his doctor he believed he had torn his rotator cuff, the group of muscles and tendons around the shoulder. He also believed he would probably need an MRI to get an accurate assessment.
But his doctor said his insurer first wanted him to get an X-ray, even though that would not show muscle or tendon injury. He got the X-ray — no bone damage was found — but was again denied an MRI. He says his health plan denied requests for an MRI three more times, directing him instead to physical therapy sessions over four months.
At one point, Mr. Emerson looked into paying cash for the MRI himself but was told it would likely cost $5,000 to $6,000. “I don’t have that kind of money.”
After 16 weeks of painful physical therapy, he said, “I finally was approved by the insurance company for the MRI. Well, guess what they told me — I had a torn rotator cuff.”
He went to see an orthopedic surgeon in Johnstown who, after reviewing the image, advised against surgery because of scar tissue that had formed around the tear.
“He said, ‘Why weren’t you here 16 weeks ago?’”
‘Original intent was good’
Health insurance, for those fortunate enough to have it, plays an important role in keeping medical care affordable. By negotiating provider rates upfront, insurers can insulate members from exorbitant medical bills and unproven, and possibly unsafe, experimental treatments.
But physicians say the use of prior authorizations appears to be expanding to more procedures and medications. Insurance rules also more often come with additional restrictions such as a limited provider network, or stricter protocols dictating when and where a patient gets a medication, test, surgery or therapy.
“I think the original intent was good, but it’s morphed into a process that is much more cumbersome,” said Philadelphia-based emergency medicine physician Ted Christopher, who serves as president of the Pennsylvania Medical Society, a statewide physicians organization.
Last year, the American Association of Family Physicians called prior authorizations “very manual, time-consuming processes” that “divert valuable resources away from direct patient care and can inadvertently lead to negative patient outcomes.”
The American Medical Association issued a statement: “The AMA believes that prior authorization is overused and that existing processes are costly, inefficient, opaque and responsible for patient care delays.”
“I have discovered that doctors are really no longer permitted to be doctors. They can no longer treat nor prescribe medications unless the insurance companies say they can.” — John Emerson
noting that earlier this year a group of industry organizations — AHIP, the American Medical Association, the American Hospital Association, the American Pharmacists Association and Blue Cross Blue Shield Association — issued a joint statement on how to improve the process.
Among other points, the statement encourages consideration of a provider’s performance, regular reviews of services to see if prior authorization is still appropriate, and timely resolution of requests.
That last point could be critical to addressing America’s opioid crisis, Dr. Christopher said. People struggling with addiction may seek less-addictive pain remedies, but “insurance companies are delaying authorization,” he said.
Thomas James is a senior medical director for Highmark Inc., the only major local insurer that responded to queries about prior authorization.
He said the concept behind prior authorizations has evolved from being largely a cost-saving measure to one that examines variations in care to decide what is appropriate.
To do that, he said, insurers rely on the recommendations of physicians’ professional groups — “evidencebased medicine,” which might involve, for example, getting guidance from the American College of Radiology on prior authorization of MRIs.
Dr. James said the Pittsburgh insurer is reviewing which services now require prior approval with an eye toward reducing the list.
“If those services are approved the majority of the time, why bother everybody with it?”
A too complicated process
For now, patients may still face “pre-auth” battles with insurers over care.
Mr. Emerson said he’s resigned to having an aching shoulder — “I think I’m just going to have to live with it until they put dirt on my face.”
A month or so ago, a dispute with a different insurer surfaced again, this time involving his wife.
Ms. Emerson had been taking a daily 30-milligram capsule for anxiety for two years, but her physician said she needed to double the dosage. The Emersons’ plan covered one daily 60-milligram capsule. The higher dosage makes her sick to her stomach.
Her physician twice called the insurer, asking authorization for Ms. Emerson to receive two 30-milligram capsules daily, one in the morning and one at night. The requests were denied.
Mr. Emerson considered just buying the 30-milligram capsules outright — then learned the prescription would cost an unaffordable $538 for a month’s supply.
Highmark’s Dr. James said there may be different reasons a specific dosage may be required by an insurer. Pharmaceutical companies, for example, may charge the same for one 60milligram capsule as one 30milligram capsule, which would double the cost.
Eventually, in Ms. Emerson’s case, the insurer suggested having her physician call a doctor on the insurer’s staff.
After the two earlier unsuccessful appeals, her physician balked, saying she didn’t have time to make multiple requests for every patient.
She also recommended Ms. Emerson resume taking the larger dose, which continues to make her throw up.
Dr. Christopher estimated 90 percent of insurance appeals get approved eventually, but the prior authorization process complicates an already complicated health care delivery process.
He added: “I truly believe the insurers think that we’re all in this together. I really think they’re trying to cut down the size of this thing, with health care costs being what they are.”
But when treatment is delayed, he said, “It’s the patients who suffer.”