When Health Insurers Give Patients the Runaround, Lives Are Lost

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Michael Otieno, a pharmacist, dispenses anti-retroviral drugs at the Mater Hospital in Kenya's capital Nairobi, September 10. Patients living with HIV can keep the disease suppressed for decades, but only if they strictly follow their prescription regimen. Profit-focused insurers are impeding medication access through a bureaucratic process known as "prior authorization." Thomas Mukoya/Reuters

HIV/AIDS researchers just made a breakthrough discovery—patients who start taking anti-HIV medications as soon as they learn they're infected are over 50 percent less likely to develop full-blown AIDS than patients who delay treatment.

Quick access to medications saves lives. But profit-focused insurers are impeding that access through a bureaucratic process known as "prior authorization," which endangers patients' health by forcing them to wait days or weeks for their prescriber-approved medicines.

Lawmakers must overhaul the prior authorization process to ensure that patients and their care providers—not insurance companies—decide the best course of treatment.

Health insurance plans currently restrict patients to a certain set of covered medications. If a patient's provider prescribes a drug not covered under a plan, the patient can seek "prior authorization" from her insurance company to take the medicine.

Too often, insurance companies deliberately make the prior authorization process difficult and time-consuming to prevent patients from accessing costly but lifesaving medicines.

Each insurance plan has its own set of covered drugs, prior authorization process and criteria for approval. Those drugs and criteria change frequently. That means clinicians and support staff—who generally conduct the prior authorization appeal on behalf of their patients—waste significant time navigating insurance bureaucracies. The average medical practice spends 20 hours every week helping patients with the prior authorization process, according to a Health Affairs study.

That wasted, uncompensated time costs doctors and nurses money. The typical medical practice loses up to $85,000 each year dealing with prior authorizations and other insurance bureaucracy. Health care providers inevitably pass these costs on to patients in the form of higher prices.

The purposefully complicated prior authorization process doesn't just cost patients money. It also may cost them their health—and in some cases, their lives. About 7 in 10 physicians report that the average prior authorization request takes several days to process. During that time, sick patients go without their doctor-recommended treatments.

Sometimes patients are kept waiting far longer to receive their doctor-recommended, FDA-approved medications. Ten percent of physicians experience average wait times longer than a week when requesting a medication on behalf of their patients. One health care provider related the story of a cancer patient who "died before he ever received prior authorization. It took weeks."

As medical director of one of the largest AIDS treatment centers in New York, I've seen firsthand how drawn-out prior authorization appeals harm patients with serious chronic diseases like HIV/AIDS. HIV treatment is evolving rapidly—no "one size fits all" treatment is appropriate.

Patients living with HIV can keep the disease suppressed for decades—but only if they strictly follow their prescription regimen. Patients who miss just 5 percent of their doses can suffer a spike in their viral loads, according to a study published in the American Journal of Managed Care.

Higher viral loads sicken patients, increase the risk of spreading HIV to others and even enable the virus to adapt and become resistant to treatment. In short, HIV can spiral out of control in a matter of days or weeks while patients wait for insurers to approve their prior-authorization request.

In addition to prior authorization hurdles, many plans use "step therapy," which requires patients to try older, less expensive—but less effective—medications and become sicker before the plan approves a physician's originally prescribed regimen.

While prior authorization can be a legitimate cost-containment strategy, it can be problematic for conditions that require highly individualized treatment plans like HIV/AIDS.

Lawmakers must crack down on prior-authorization processes designed to prevent timely access to lifesaving drugs. To save money and enable patients to start their treatments on time, all insurers should be required to use the same standardized prior authorization process and forms.

To streamline the authorization process, insurers should provide clinicians and patients with a clearly defined number to call or website to access. That will stop insurers from dragging out authorization requests by constantly transferring doctors from one customer service representative to another.

Insurers must also respond to prior authorization requests within a set time limit. Providers must realize that if the insurance company fails to respond promptly, the prescribed medicine wins an automatic authorization. Better awareness and enforcement of this system will prevent insurers from stringing patients out for weeks on end.

The convoluted prior authorization process makes it more difficult for patients to access the medicines their providers prescribe. Reforming the process would rein in abusive insurer practices and ensure better health care for sick Americans.

Joseph P. McGowan is co-chair of the New York/New Jersey chapter of the American Academy of HIV Medicine and serves as medical director of the Center for AIDS Research & Treatment at the North Shore University Hospital.