This commentary is by Diane Roston, who is on the clinical faculty at the Geisel School of Medicine at Dartmouth and is a physician at West Central Behavioral Health in Lebanon, New Hampshire.
Imagine that when you go to pick up a refill, the pharmacist tells you that your insurance won’t cover it.
“But I’ve been taking this medicine for years: two 10 mg tablets in the morning and one in the afternoon. It works well. And it’s generic,” you say, surprised.
“I know,” the pharmacist replies, “but now it requires prior authorization.”
Or picture this: You’ve been on a diuretic to help your kidneys remove excess water and sodium for several years to maintain fluid balance and prevent leg swelling. Your new health insurance requires prior authorization to cover this medicine, even though it is generic, inexpensive and effective. You worry that you’ll run out of the medicine soon.
When health insurance companies initiated prior authorizations years ago, the focus was on restricting the use of costly name-brand medications or treatments. As a physician, I applauded: Encourage doctors to prescribe generics and limit spending on flashy pharmaceuticals.
Gradually, my feelings began to change. Take the first case above. After the pharmacist initiated an online prior authorization request, my assistant completed the form, which I reviewed and signed. Although most of this process is computerized, parts still involve human input.
Days later, we received a response: Request denied.
I confirm that the medicine is, indeed, on the company’s covered medications list. I call the company’s peer-to-peer telephone appeal line. Forty-five minutes and four phone transfers later, I reach a peer who is a nurse from a different specialty. After I explain that this medicine is on their formulary — the official list of prescription medications approved for use — for this FDA-approved diagnosis, and that the patient has been stable on it for years, the peer tells me the appeal is denied: “Quantity limit. Only one pill allowed per day.”
“Can I write one prescription for one 20 mg pill in the morning and another one for one 10 mg pill in the afternoon?” I ask.
“Yes,” she replies, “as long as it’s one pill of each per day.”
From the health insurer’s perspective, quantity limits aim to ensure appropriate doses, but in this case, the dose is the same before and after the prior authorization was granted.
Or take the second example, involving a patient who had been taking a complex medication combination to treat several chronic medical conditions, including reduced cardiac function. He and his doctors, including me, had arrived at a generic, inexpensive medicine balance that maintained his health without side effects.
Due to a delay in processing the prior authorization request, he missed three days of the diuretic and ended up in the emergency room with leg swelling and shortness of breath due to fluid retention. Ultimately, the prior authorization was denied. “The med was flagged due to risk of a serious interaction with one of my other meds,” he explained. “But I’ve been on both meds for a long time, with no problems. I know the risks. I choose to take them.”
How much time is spent in this process? The 2024 American Medical Association Prior Authorization Physician Survey of 1,000 U.S. physicians reported that, on average, a medical practice completes 39 prior authorization requests per full-time physician per week, taking an average of 13 hours per week per physician and their staff.
Prior authorizations take time. But does this process save money? One 2023 working paper from the University of Chicago School of Public Policy found that when Medicare required prior authorization for expensive new medications, the savings averaged $95.88 per Medicare recipient. However, this study also found that of the people whose medication coverage was denied, about half took a substitute medication, which might or might not have been as effective. More significantly, half took no medication at all.
Another study published in Health Affairs in 2021 found that drug utilization management in the U.S., which includes prior authorization, costs $93.3 billion annually, including $6 billion for insurance companies and $35.8 billion for patients.
Eighty-eight percent of physicians surveyed in the AMA study reported that it leads to greater overall healthcare utilization because of increased emergency room services, urgent care visits and hospitalizations.
Dr. Jack Resneck, a dermatologist and former AMA president, described a prior authorization rejection for a medication that had transformed a patient’s severe eczema. The insurer’s reasoning: The patient’s condition had improved too much to qualify. “You have to take the patient off the medication, let them flare, let their disease get terrible, let them start missing work again,” Resneck said, “and then we’ll approve it.”
After I complete, review and converse peer-to-peer for yet another prior authorization request, I wish my time could have been better spent.
I’d like to get back to taking care of patients.
