Two times in the past month I have dealt with a patient referred to a specialist who ordered a medication that required a prior authorization. The PA is process by which health care providers must obtain advance approval from a health plan before a specific procedure, service, device,supply or in this case medication can be prescribed for the patient to qualify for payment coverage. Other terms used for this process include: “pre-authorization,” “pre-certification,” “prior approval,” “prior notification,” “prospective review” and “prior review.”

When I referred the patient back to the specialist to get the PA, it returned like a boomerang. No input, not even a suggested substitution from the specialists. One specialist was endocrine, the other GI and both patients were back in my clinic facing a prescription that was over $600 per month out of pocket. Why were they sent to the specialists, I asked myself? Now,I am doing clinical work very part-time and PA happen with meds I prescribe as well, but usually I know which medications we have to try and show failure before jumping to the one that requires a PA. The specialists’ PA becoming my problem, along with the associated work, was new.

A quick search revealed a growing number of articles and studies being spent on prior authorizations (PA) by both primary care andspecialists. I found nothing on my issue, but PA in general are a time consuming problem for docs.  

One of the first studies, a 2013 study by family medicine colleagues, showed that $2,000 to $4,000 per full-time equivalent physician was spent on PA activities each year. This study demonstrated that it could be measured and PA took time and staff.  A country doctor blogger asked maybe in jest but certainly I frustration, what the CPT code or the billing code was for doing PA.

A 2018 study by the AMA documented significant increase in PA in the last five years. One out of three physicians have staff dedicated only to PA activities. More than nine in 10 of the study respondents said PA had a significant or somewhat negative clinical impact, with 28% reporting that PA had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.

PA cause treatment delays and most patients wait from 2-5days before any answer is received. One creative physician blogged that she was able to buy the Cipro liquid from a pharmacy in her state for one sixth of the price $20 instead of $135 and sold it at cost to the parents of her patient so treatment for their child’s Otitis Media (ear infection) could start the next day. Fortunately, they lived in one of the few states where physicians can dispense medications to patients.

In contrast, our physician neighbors to the north in Ontario spent 2.2 hours per week interacting with the Ontario single payer which was significantly less than the 3.4 hours spent by US physicians who interact with multiple payers. Even more astounding is that US nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans--nearly 10 times that of their Ontario counterparts. In the US, those interactions include formulary issues, claims and billing, quality data reporting,credentialing and PA. Of note, only the first three in that list are issues in Ontario. This 2011 study compared both specialists and primary care physicians in small practices in both countries.

Clearly PA are a problem, more time with the insurance company and pharmacy is not rewarding or what physicians went to medical school to do. PA were created for a reason, to ensure value and quality and rope in the exorbitant costs of our health care in the US. Both patients and doctors are in love with technology and the latest and greatest that is not necessarily proven to work. That is another blog post.  But while PA do eliminate unnecessary use of technology, misuse of brand name medications and pointless procedures, there are consequences like the delay ordenial of appropriate and necessary treatment. An example of my own: The lidocaine patch for treating back pain in the effort to avoid the use of narcotics in a patient prone to misusing opioids.

Obamacare (ACA)did put some protections in place related to PA. Health plan agreements after the passage of the ACA cannot require PA to see an OB-GYN, and patients can pick their own primary care physician (including pediatricians or OB-GYNs). PAare prohibited for emergency care at an out-of-network hospital. Access to an internal and external appeals process was also put in place.

I came across a PA handy toolkit published by the AMA in2015. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/premium/psa/prior-authorization-toolkit_0.pdf.My research and the information gleaned from it on PA brought me to two conclusions.  First, the buck stops with the primary care physician for assuring that the patient gets what they need.We are and will continue to be the unsung heroes in health care doing the best we can at practicing cost effective medicine while addressing the needs of our patients. Woe is me, I can hear the violins playing now. More importantly, our current efforts in the US to control costs and medical decisions by creating administrative hoops is not keeping the patient at the center of the effort. The good news is that professional organizations like the American Academy of Family Physicians and the AMA are working to improve PA. Hopefully their efforts will not turnout to be too little, too late.