COVID-19 Can’t Be The Only Reason We Curb Prior Authorization

0
185
Physician in medical face mask holding syringe while senior lady keeping arm on cushion stock photo

One of the few solaces we can take from this COVID-19 crisis is that it has highlighted the need for timely, accessible health care for all patients. But we can only wonder just how long this feeling will last.

As a rheumatologist based outside Philadelphia, I treat patients with various forms of arthritis. Care must be individualized as each patient has their own individual health variables, be it a potential drug interaction or an underlying medical condition that may preclude the use of a medication we might otherwise use. 

This does not sit well with insurance companies. If it’s not part of a regimented set of health guidelines, physicians are often forced to justify their treatment plans through a process called prior authorization, where the insurance company must approve a prescribed treatment before the patient can receive it. Whether you’ve been a part of it as a provider or patient, you know the slowdown this causes.

The process starts with office staff submitting information to the insurer. If care is denied, next comes a “letter of medical necessity” explaining the rationale, often followed by a “peer-to-peer” phone call, where I must convince an insurance doctor that the care I have prescribed is appropriate. This doctor is rarely in the same specialty as me and makes decisions based on cookbook “guidelines,” i.e. mandates, that may not even apply to my patient.

I once had a patient with inflammatory arthritis of the spine. I prescribed a biologic, which is the standard of care. The insurer denied it and advised me to use a drug akin to Motrin instead. This would be analogous to a pipe bursting and being told that I should use a mop rather than call a plumber. The 20 minutes I spent to get the medicine approved was time taken away from other patients.

Another patient of mine presented with ankle pain – X-rays were negative. I ordered an MRI which was denied. My peer-to-peer discussion was with a doctor not even trained in my specialty. She recommended physical therapy first, stating that “Some people get better with PT.”

The patient ultimately proved to have an occult fracture and the insurer’s “recommendation” was essentially malpractice.

For a physician, it is extremely frustrating to be at the mercy of an insurer’s decision. If a patient suffers an adverse outcome because of insurance mandates, I am the one who is sued, not the insurer. 

Insurance companies can certainly determine coverage based on financial considerations. However, when the decision making involves the medical facts of the case, the insurer is then practicing medicine without ever having seen the patient.

Recently, because of the COVID-19 pandemic, many states and insurers have temporarily lifted these restrictions to provide greater access to care. I commend these efforts, but we need a permanent solution to prior authorization.

Recently, I wrote a letter to the chair of the Pennsylvania House insurance committee to encourage movement on House Bill 1194  This bill would curb restrictive prior authorization and step therapy (fail first) practices imposed by health insurers. It would also ensure that peer to peers are in the same specialty as the prescribing physician.

If they can lift these bans for COVID-19, that means they understand the backlog these processes can cause. And unfortunately, my patients, like millions of others in the state, cannot wait for care any longer.

HB 1194 is currently sitting in the insurance committee awaiting further action. I urge you to stand with me and reach out to the committee members to encourage them to push this legislation forward. 

Because if the last few months have taught us anything, it’s that we need to fix our broken health care system immediately. This would be a good start.

Mark Lopatin, MD, FACP, FACR, FCCP is the 2nd District Trustee with the Pennsylvania Medical Society.