Prior authorization (PA) is a term most of us have heard before ―medical professionals and patients alike. We associate it with going to the pharmacy, finding that not only is our medication not ready for pick-up, it cannot be filled yet due to PA. PA generates feelings of confusion and anxiety, but it is also responsible for creating an enormous patient care burden. I am a registered nurse, employed as a supervisor, overseeing nurses. I am also an advanced practice nursing student, learning how to diagnosis and prescribe medications. I face the insane semantics of PA as both a healthcare professional and a patient.

As a RN, I see PA denial forms as they come through the fax machine. I am often the one who hands off these forms. The forms, when received, are accompanied by apprehensive looks on a physician’s face. The denial form recommends “equal” drugs for substitution, yet a physician prescribed the denied medication for a reason. The physician prescribes according to best clinical judgment, accounting for pharmacodynamics, potential drug and food interactions, as well as individual patient variables such as likelihood of compliance.

While drugs in the same class do produce similar effects, they are not the same. Let me ask you this―If drugs were “just all the same” and could be substituted for one another without hesitation, then isn’t it obvious that there would be no need for multiple drugs?

A recent AMA survey of 1,000 physicians, showed 28% reporting serious adverse effects occurring in their practice such as death or life-threatening events, permanent bodily damage, hospitalization and disability secondary to PA. Additionally, nine in 10 physicians see major patient-care delays.

Current news focuses on ways PA is being “fixed” with the automated processing of coverage requests. Can PA be fixed so easily? Patients are dying…. Look at lawsuits across the country: A teenager with a diagnosis of epilepsy died from a fatal seizure without her medication; a 23-year old nearly died when Aetna denied coverage for intravenous immunoglobulin to treat immune deficiency. Both patients had been taking medication covered by insurance for years when, suddenly, PA became a requirement. How many deaths will it take before we realize PA cannot be fixed?

I know PA endangers patient well-being. It also steals autonomy from prescribers who no longer have the earned privilege to prescribe and plan patient care the way they intend to.

A recent article published in the Journal of Public Economics claims that physicians are not truly informed. Disturbingly, the author has a Ph.D. in economics but no medical background. How can the author make such assertions?  Yet judgments concerning high pharmaceutical complexity and prescribing intricacies are made.

The article also asserts that PA reduces high-risk prescriptions and lowers prescription cost. Let’s make this simple —the lower costs are for insurance companies only. The patient spends time and money on more healthcare visits because of side effects, hospitalizations, and even the development of new co-morbidities as a result. Families suffer from the death of loved ones who die only because an insurance company denied PA —essentially with insurance companies calmly declaring: We know the physician thinks you need this medication but trust us… you really don’t need this.

But the issue here is much deeper and more convoluted than stringent PA requirements and overwhelming denial rates. The issue is that people die because in America insurance companies are legally allowed to prescribe medications.

The issue is not simply with PA― it is the travesty of America and the majority’s absurd conception of what appropriate medical treatment entails, the distorted ethics which haze the purpose of our healthcare system, and ultimately―it is our nation’s chilling downward-spiral as insurance companies override the trained physician.

Most of us do not see this, and it is right in front of our eyes. This issue is self-perpetuating, terrifying, and very dangerous.

PA kills because inept insurance companies and those with a background in business are the ones writing the prescriptions now. They say what medication we may take. Wow…. How very very scary.

Christine Alexandra Bottone lives in Hartford. 

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3 Comments

  1. Americans tend to think that Health Care is to cure disease. It follows that any prescription, no matter what the cost, should be available if a doctor prescribes it.
    Health care costs have reached the breaking point for a middle class family. Should we, as a society, allow any doc to prescribe a $10,000 a month medication when a $100 a month prescription is 99% as effective?
    When we come to terms with cost, we will have to decide how to provide the most care to the most people within our budget? At that time, we will be able to find a reasonable compromise on Prior Authorizations.

  2. Prior authorization proved to be a serious problem for me. Visited my physician late on a Friday suffering from extreme lower abdominal cramps, mild diarrhea and troublesome urination. Doctor order a CT scan but could schedule it as it was after hours. Told me to call early Monday AM. Did so – called the insurance company – no one was available because it was a Monday holiday. Could have had the scan done that morning while the symptoms were extreme. Finally the PA came through – denied. Doctor called to explain why. PA was finally issued. Could not reschedule the scan until Thursday AM. Symptoms had subsided substantially by that morning. Scan did reveal the likely cause to be diverticulitis.

    Exactly what could have been missed by doing the scan after the symptoms had subsided?

    Guess I’ll find out as time goes on. Not a happy situation.

    Similar issue with my prescribed meds – what the doctors order is NOT on the correct “Tier.”

  3. Medicare for All and an end to the private insurers are the only answer. Yale just released a study outlining not only the cost savings of a M4A system but it also estimated the number of people that die unnecessarily every year because of private insurance company practices. This has to end.

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