The problem with prior authorization in health care

If you've ever undergone a medical procedure, you've probably encountered prior authorization. It is the process your doctor must go through to determine what portion (if any) your insurance will pay. Prior authorization is defined according to HealthCare.gov as a decision by your health insurer that determines if certain treatment plans, prescription drugs or durable medical equipment are "medically necessary." The process is time-consuming for medical providers and nerve-wracking for patients awaiting treatment.

Some states now seek to reform this practice.

A medication I've been taking for the past 12 years recently required prior authorization because our insurance plan changed when my husband got a new job. My prescription was denied. What should be an exciting time of new beginnings for our family is instead fraught with worry while I wait for my rheumatologist to file an appeal.

The author and her family attend the Arthritis Foundation’s ‘Jingle Bell’ Walk. Bonnie Jean Feldkamp

I've been taking the same biologic medication for my psoriatic arthritis since 2010. I know this fight well. I was first denied this prescription in favor of a different, less expensive one that my insurance required I try first. Insurance companies call it "step therapy"; I call it a nightmare.

The American College of Rheumatology found in their 2020 patient survey that almost half (46%) of patients reported that their insurer subjected them to step therapy requirements. Another 48% of patients reported that their provider needed to obtain prior authorization before obtaining a prescription.

Prior authorization, step therapy and tiering are supposedly to ensure a high standard of care for patients and to prevent waste, fraud and abuse. But while I jumped through the required hoops and took the medication the insurance company required, my condition worsened. Within six months, I deteriorated from walking with a cane to being bedridden. I resigned from my job and my plans to have another child were canceled.

Our American health care system is broken, and it is the patients who pay the price. After months of appeals and what I can only imagine was mountains of paperwork from my care team, I was finally permitted to begin biologic treatment. This was a game-changer for me. It gave me my life back and in 2015, I had my beautiful son.

Now, here I am again, fighting for access to a medication I know works for me. It was, and is, hard for me to see anything but greed in this process. I understand that medication guidelines exist for a reason. But I have a hard time understanding why an insurance company would require prior authorization for a chronic illness medication that I've already been taking. Nor do I understand how they can justify denying it now. The only concern I can see they may have is the fact that my prescription will cost them over $12,000 a month. Biologics are expensive.

Prior authorization reform

The American Medical Association, along with 16 other physician, patient and health care organizations such as the American College of Radiology, the American College of Rheumatology and the American Academy of Family Physicians support prior authorization reform including what's called the Gold Card system. Texas passed legislation to implement this in September. Kentucky currently has a bill introduced for Gold Carding as well. It doesn't remove prior authorization completely, but it helps experienced physicians with a prior authorization approval rate of over 90% over a six-month period. These doctors could become "Gold Carded," or saved from having to submit prior authorization requests for certain services.

Guidelines are important and safeguards are needed. However, when I read that my medication is denied because "(t) here are medical treatments for many conditions that have lower-cost, but equally effective alternatives available based on clinical guidelines," I hear that money is the driver, not concern for my care. What does it matter if another medication will help me save on my copay if the medication isn't effective and I lose my job in the process of giving it a try?

Our health care system needs an overhaul, and the prior authorization process is a good place to start. I want my rheumatologist to focus on my care and I want access to the maintenance medications I need to sustain my quality of life. My rheumatologist will, of course, appeal the prior authorization denial, which will require more rounds of paperwork. I am confident we will win, and hopefully, we will win before my doses on hand run out.