During an early surgical rotation, Kansas City medical student Victoria Gordon felt a wave of heat flash over her entire body during a Caesarean section she was assisting. It was a feeling she knew all too well from years of struggling with the symptoms of polycystic ovary syndrome (PCOS).
It was so bad that Gordon had to scrub out from the procedure. She remembers fumbling back amid a cloud of embarrassment into a chair that a colleague had set out in the operating room.
The experience was the most excruciating she’d had yet as a medical student. “I was feeling ill all the time and being under such strenuous conditions made it worse,” recalls Gordon, who is finishing her fourth year at Kansas City University College of Osteopathic Medicine and will begin an emergency medicine residency this summer at HCA Houston Healthcare in Kingwood, Texas.
Gordon found effective and lasting relief with a life-changing drug that restored her energy, helped manage her symptoms, and made hours of standing in the operating room a viable option.
Then came prior authorization.
A request for a prescription refill sent her on a whirlwind trek to check this box. Gordon, an AMA member, found herself on the phone for hours, getting transferred from her medical school to the insurer, pharmacies, her doctor—and back again.
Her story underscores the madness of prior authorization, a health plan cost-control process that requires physicians to qualify for payment by obtaining approval before performing a service. Prior authorization is overused, costly, inefficient, opaque and delays patient care, as the 2021 AMA survey of more than 1,000 practicing physicians (PDF) revealed.
More than 90% reported that prior authorization was delaying access to necessary care, and 82% said it sometimes leads to treatment abandonment. Notably, of the physicians surveyed who treated working adults, 51% reported that prior authorization had interfered with a patient’s ability to perform at work.
The AMA advocates on every front to reform prior authorization so that patients won’t face care delays and interruptions and physicians can focus on patients rather than paperwork. Read about other prior-authorization stories from patients and physicians at FixPriorAuth.org/stories.
Gordon, an active member of the AMA Medical Student Section has been chronicling her experience with prior authorization on Twitter (@futuredocgordon). In an interview, she spoke in detail about her painful firsthand experience, how it nearly endangered her medical training, and why she's newly committed to making sure future doctors practice in a saner environment.
“Something has to change,” she recently wrote on Twitter.
AMA: You’ve written eloquently on Twitter about your recent experience with prior authorization. Would you elaborate on that for our readers?
Gordon: I’ve had the PCOS diagnosis since I was 16. I'd been prone to passing out and feeling sick. I felt hungry all the time, even if I’d just eaten.
I got on this medicine—semaglutide, the brand name is Ozempic—to treat my insulin resistance. Suddenly, I wasn’t passing out or having any other symptoms that were negatively affecting my life. It was treating so many things for me: it changed my life. It just made me feel better. I ended up losing a bunch of weight, about 70 or 80 pounds.
When I turned 26, I had to get insurance through my medical school. It was crazy expensive, $3,000 a year. This didn't include all the money I spent on doctor's visits and prescriptions that aren't fully covered.
I went to get my medication refilled and heard, "Well, there's a problem. You need a prior authorization." And I was like, "How can that be? You guys sent us this list of things that are going to require step therapy and prior authorization. I have it pulled up on my computer right now and my medication is not on there."
And the administrator said, “Well, we have this other list that we're using that says it's on there."
I called the school’s human resources office. They had outsourced the plan. They said, "No one at the school can help you. Call the company that got this plan put together.” The company said, "Well, we don't actually handle that. We just put the plan together, so you have to call your insurance."
I call my insurance. I'm on hold for 30 minutes. They say, "Oh, let me transfer you to our pharmacy service because we outsource our pharmacy." The pharmacy says, "We don’t see that this needs a prior authorization. This is actually going through your insurance’s pharmacy department." They transferred me over there. And I talked to them and they say, "You have to go to your doctor and talk to them."
AMA: So, the insurance company is basically kicking it back to the doctor and saying, "We need the doctor to complete the prior authorization paperwork."
Gordon: Correct. So, I call my doctor. They’ve completed the paperwork. I call the insurance again and I do the same process where they kick me over to the other pharmacy department who kicks me back to their pharmacy department. So far, I've spent probably 15 or 20 hours on the phone. They kick me around and they say, "We never got it."
AMA: That must have been so frustrating. You know that most patients would have just given up and said, "OK, I'll press my luck, and I'll do with some other medication or I'll cross my fingers. Or hopefully I'll be okay without it." But you kept going!
Gordon: Yes, and the paperwork was finally submitted after more hours on the phone. The coverage was denied. When I asked why, I heard, "Your A1c is too low." Apparently, this was because I’d been on this medication.
AMA: The medication is working too well, so insurance was denying coverage for the medication. That was their logic?
I called my doctor's office and, honestly, I was pretty emotional. I said, "This medication has changed my life.”
My endocrinologist said, "Listen, Victoria, I'm so sorry. There's nothing we can do. I am watching all my patients get sicker and sicker right now because this is getting denied. I have to wait until they get sick again, and then they'll approve it and that's not what I want."
She's obviously upset and burned out by the prior authorization process and so is her staff.
My story, actually, has a happy ending. My coverage was approved. A lot of that had to do with my persistence. My insurance company knew I wasn't going to go away. They finally sent me to someone who said, “We can either get you a written appeal, or we can have your physician discuss peer to peer with our people who approve or deny these, with our medical staff."
AMA: And once that peer-to-peer conversation happened, it was resolved pretty quickly. You have subsequently been able to get a prescription renewal with the usual copay?
Gordon: I was told it will be $35, which is standard.
AMA: So even before you finished medical school, you got a heads up on the—ahem—wonders of prior authorization. You spoke a little bit about the impact this was having before you were able to get on Ozempic, to get better control of your symptoms affecting your training. Please talk about that a little more.
Gordon: I was getting sick when I had to stand for long periods of time. I would get lightheaded.
I worked around my symptoms because I wanted to be in the OR. Between every case I would eat and drink water...Since I got on this medication, I have occasionally felt the beginnings of those symptoms again, but it’s more in line with most people’s normal if they don’t eat or drink for hours. Never do I feel worried that I will have to leave a case or stop my learning.
AMA: What are you taking away from this experience as a medical student and as a soon-to-be resident?
Gordon: As a medical student, this is obviously not our focus. I don't think we write a lot of House of Delegates resolutions on it. However, it is something for us to be aware of. For me, the big takeaway is how much of a burden this was on my physician's office—which was already clearly overburdened—and how much of a burden this was on me as the patient who pays a crazy amount in premiums and money on top of that for other things.
I knew the system well enough to know how to navigate it, but most people don't have that privilege. I happen to be on a shift in my fourth-year rotation where I can take a whole day to plow through these calls. I was talking to my mom about this and said I couldn’t imagine what a burden this would be on a patient with no medical knowledge, working 12-hour days, who's unable to call, who doesn't know there's an appeal process.
— News Editor Kevin B. O’Reilly contributed to this report.