Kunal Sindhu: How prior authorisation is harming patients in the US

The process to obtain prior authorisation is cumbersome, frustrating, and diverts doctors’ time away from their patients, says Kunal Sindhu

Most insurance companies in America have implemented policies that restrict coverage of certain prescription drugs and medical services unless a patient’s provider specifically requests and receives approval for them. In theory, this process, also known as prior authorisation, could yield benefits, such as controlling excessive costs, promoting patient safety, and preventing drug misuse. Yet in practice, I’d argue that the process to obtain prior authorisation is opaque, cumbersome, and profoundly disruptive to patient care.

When I was an internal medicine intern, I regularly found that obtaining prior authorisation for the medications I prescribed was one of the most arbitrary and frustrating aspects of my job. There was usually no apparent rhyme or reason to explain why certain medications required prior authorisation and others did not. Each insurance company makes this decision separately and the diagnostic tests and treatments that require prior authorisation vary by company, so the system often felt inconsistent.

Furthermore, the process itself was harrowing. Already extraordinarily busy, I had to stop what I was doing to call the insurance company, spend an inordinate amount of time on hold, and beg a stranger (often not a doctor in my specialty) to allow coverage of a medication that I believed was essential for my patient. Sometimes, the company agreed. Yet at other times it did not, forcing me to choose between appealing the decision, which has no guarantee of success, or scrambling to find a suboptimal alternative.

I was not alone in feeling this way. A 2018 survey of 1000 American physicians by the American Medical Association (AMA) found that 69% of them find it difficult to determine if a particular medicine or service requires prior authorisation. Eighty five per cent of these physicians agreed that prior authorisation interferes with patients’ continuity of ongoing care. Notably, 60% of physicians reported phoning insurance companies to obtain an authorisation (rather than using email or fax). I imagine most of these doctors take this approach for the same reason I do: the chance to explain directly why I am prescribing a particular medication. Yet phoning an insurer is the most time consuming of the three options.

One major consequence of these inefficient and misguided policies is that busy doctors are forced to spend less time with their patients. Given how little time some doctors are able to devote to direct patient care even without the interruption of seeking prior authorisation, any extra obstacle represents a loss. Now, as a radiation oncology resident, I have a greater appreciation for how devastating these policies can actually be to patients.

A fundamental principle of cancer care is to diagnose and treat the disease early, before tumours have a chance to grow and spread. Thus, any obstacle that delays a patient’s treatment can put him or her at risk of adverse outcomes. A recent study in PLOS One, for example, found that the absolute risk of mortality in patients with early stage cancers rose by 1.2-3.2% for each week that treatment initiation was delayed.

Additionally, early diagnosis and treatment can reduce the disease’s financial impact. This is no small matter. Patients with cancer who experience financial difficulties linked to their disease are at risk of falling into debt and declaring bankruptcy, not taking their medications as prescribed in order to save money, and experiencing a decreased quality of life. One US study of more than 2500 patients with early stage breast cancer even found that 45% of black, 36% of Latina, 23% of Asian, and 22% of white patients had to cut their spending on food to fund their treatments.

Unfortunately, the need to obtain prior authorisation often delays the initiation of radiation therapy. In a recent survey by the American Society for Radiation Oncology, 93% of American radiation oncologists reported that prior authorisation delayed treatment initiation by an average of one day or more. Worse, nearly one in three radiation oncologists (31%) said that the average delay was greater than a week.

In the interest of patients, the prior authorisation process must be reformed. Fortunately, there are steps that could improve the current state of affairs. Firstly, the decisions of physicians with track records of excellent clinical care and fidelity to evidence based treatment guidelines should be less frequently subjected to, or even exempt from, review. Some insurers are already doing this, but they’re in the minority; currently only 8% of American physicians report working with insurance plans that offer exemptions. This is wasteful, delays treatment, and directs resources away from reviewing the decisions of providers whose practices may benefit from further examination.

Secondly, the scope of prior authorisation should be scaled back. The number of prescription drugs and medical services subject to prior authorisation has been growing in recent years—a fact that has been noticed by clinicians. In the aforementioned 2018 AMA survey,  most of those polled reported that the use of prior authorisation had increased over the past five years for prescriptions and medical services (88% and 86%, respectively). While certain treatments may theoretically benefit from review, there is no reason that common definitive or palliative radiation therapy regimens should be subjected to additional scrutiny.

Thirdly, physicians should be made aware of whether a treatment will be subjected to prior authorisation at the time the treatment is ordered. Automation can help with this. After an order is placed in the electronic medical record (EMR), a notification informing the physician of the prior authorisation requirement would be helpful. Even better would be the ability to submit a short paragraph explaining the treatment rationale directly in the EMR, potentially saving physicians hours of time that would otherwise be spent wrangling with insurance companies.

The status quo of the prior authorisation process is jeopardising the health of American patients. And with expensive novel therapies continuing to become available, this problem is only going to escalate. If insurance companies are unwilling to reform the system, Congress should step in to implement these common sense solutions. American patients in need of care and treatment cannot afford to wait any longer.

Kunal Sindhu is a radiation oncology resident in New York City. Twitter @sindhu_kunal

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.