The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

 

AMA President Jack Resneck Jr., MD, shares how prior authorization creates time-consuming burdens, making it difficult for patients to receive the care they need.

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Voice-over: We've enlisted AMA President Dr. Jack Resneck Jr. to share how cost control practices delay care, and how patients can help the AMA tackle prior authorization. When patients try to fill a prescription at a pharmacy, they're often told that their insurance company won't pay for the medication unless their physician obtains approval. This tactic, used by insurance companies to control costs, is called prior authorization. Here's how Dr. Resneck explains things.

Insurance companies want to spend less. I think it's largely an effort by health insurance companies to spend less money. What doctors are experiencing today and I know patients are finding the same thing when they show up at the pharmacy to try to fill prescriptions, is that it now is being used for just an incredibly broad variety of medications.

Prior authorization complicates decision making. It means that when we're sitting down together as a team, a doctor and a patient, working on what's going to be the best next steps to diagnose and treat that patient's condition, there's this whole other part of what has to take place during that interaction of the physician trying to predict what treatments they'll actually be able to get for that patient, even if that patient has health insurance.

Fighting rejections is time consuming. Many of us have people in our offices, staff, who do nothing but focus on filling out prior authorization paperwork. In my own office, we have to rotate that among staff because it's such a painful job that nobody could really do that all day long. So it really is diverting resources in addition to delaying really important care that patients need.

Prior authorization barriers are harmful. We as physicians often find ourselves fighting over and over and over through a series of appeals to get the patient the medication or the test or the treatment that they need. If you stick with it and are willing to fight through multiple rounds of this, I find that physicians can often win the battle. And in some ways, the percentage of the time  that we do being so high is evidence that the health plan didn't need to put up these barriers in the first place because the physicians are prescribing appropriate evidence-based treatments, and the health insurer eventually recognizes that. But in the meantime, patients are not getting treated.

Previously covered services may change. The other thing that we run into is a continuity of care problem, where patients find a medicine that works for their condition, for their chronic disease, and they're on it, and they're doing great. And then all of a sudden a year later, we get a note from the insurance company that says—hey, your refill has triggered another prior auth requirement. So one of those repeat prior auths got triggered. I dutifully filled out pages of paperwork to explain to the insurance company that the patient was doing great and their disease had really improved on the drug. I got back a rejection.

Efforts to fix prior authorization are underway. We're beginning to see some states that have taken some action from limiting how many things can require prior auth to trying to fix continuity of care problems, where patients get inappropriately taken off of those medications that they're stable on. We gave the health plans a few years, we worked with them, but unfortunately, the health plans didn't act on those promises. And we see patients really still suffering.

Share your stories: If we're going to be successful in convincing Congress and state legislatures and others to step in and fix this problem, they need to hear, not only from physicians, and we're speaking up loud and clear, but they need to hear from you as patients as well.

Voice-over: From high cholesterol to sleep apnea and long COVID, learn what doctors wish patients knew about today's health care headlines at ama-assn.org/wish.

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