Who’s choosing Americans’ medications — doctors or insurers? The bane of prior authorization

New Year’s Day, the day of new beginnings, is a day health care providers like me dread. It starts the annual deluge of requests to renew “prior authorizations” — a bureaucratic tactic that insurers use to see how dedicated we are to the treatments we choose for our patients.

Walking into the office on the first workday after New Year’s Day we’re inundated by voicemail messages and emails from frantic patients unable to obtain refills for their prescriptions. Until we complete those renewal requests — and they’re approved — insurers won’t continue coverage for many medications. In the meantime, patients must either pay for them out of pocket or go without.

Prior authorization is a process that requires a provider to submit an application justifying why a patient needs a particular medication, medical device, or procedure rather than a cheaper alternative preferred by the patient’s insurer. There are several circumstances in which a provider must obtain authorization for something she or he has prescribed, usually thoughtfully and rationally. For some medications, it is required before an insurer will cover a higher dose or higher frequency of administration than the insurer feels is safe. For others, prior authorization is necessary for coverage no matter what the dose or frequency. Depending on the insurer, it may also be required if prescribing more than a 30-day medication supply or, in some cases, less than a 90-day supply.

The process must be repeated annually or, in some cases, multiple times a year.

Being regularly compelled by insurers to reconsider and justify treatment decisions we have made in our patients’ best interests, providers are increasingly wondering who’s actually doing the prescribing — us or people with no medical training who know our patients’ names only because they’re reading them on computer screens?

Years ago, insurers responsibly used prior authorization to steer providers away from brand-name medications to cheaper — and usually equally effective — generic alternatives. But over the last decade, prior authorization requirements have exploded. These days, they’re even required for generic medications for which no cheaper effective alternatives exist. Prior authorization requests are approved more than 80% of the time, raising serious concerns that insurers are reducing their costs at the expense of patients by relying on the ability of time-consuming prior authorization requirements to deter prescribing.

In a 2010 study analyzing new Medicaid prior authorization requirements for several bipolar disorder medications, for example, one-third fewer patients had started on those medications four months after the prior authorization program was implemented, a massive decrease unlikely to have been driven by prior authorization denials alone.

For every prior authorization request, a provider can lose up to an hour or more wading through an administrative quagmire. There are often labyrinthine phone trees to maneuver through, patient records to unearth, and faxes — yes, faxes — to be sent.

Even after providers do everything insurers ask, there’s no guarantee the request will be approved, and it can take days or weeks to hear back. All the while, patients hung up in the process are waiting for their medications and others are growing restless in the waiting room.

Websites such as Covermymeds have made prior authorization easier in recent years by digitizing the process for many insurers, though not all of them. But since a large number of insurers outsource their prescription drug management to pharmacy benefit managers, it’s not uncommon on these websites to be told you’ve submitted a request to a company that has no pharmacy benefit record for your patient.

Insurers claim that prior authorization protects patients from unsafe prescribing. The notion that insurers can make safer prescribing decisions than treating providers is highly questionable, since many providers have seen prior authorizations seriously harm patients. In a 2018 survey of 63 children with epilepsy whose antiepileptic medications required prior authorization within the previous year, 23 had to wait at least a week when starting a new antiepileptic, and 11 missed dosages of current medications due to prior authorization delays. Of those 11 children, seven had increased seizures while awaiting prior authorization, including one who was hospitalized after developing status epilepticus, a potentially fatal condition.

Insurers also argue that prior authorization requirements are necessary to limit rapidly rising prescription drug expenditures. Yet providers like me see how they actually increase overall costs by leading to emergency room visits and hospitalizations when patients go without their medications. What’s more, every year it costs nearly $70,000 for a physician to interact with insurers, and much of this is due to prior authorization.

Prior authorization affects all specialties. It strikes psychiatry particularly hard since, due to poor reimbursement for their services, most psychiatrists don’t have administrative assistants to help with the process. As a psychiatrist, I’ve seen how prior authorization can pose serious risks for patients with mental illness or addiction. They’re associated with more frequent medication discontinuation by people with mental illness, increased emergency room visits for people with bipolar disorder, and higher rates of imprisonment for people with schizophrenia. They’ve also been implicated in overdose deaths after delaying life-saving opioid addiction treatment, such as Suboxone.

A colleague and I recently published the results of a national survey of psychiatrists that revealed how prior authorization alters prescribing behavior in ways that might account for some of these findings. Two-thirds of those who answered the survey admitted at least occasionally refraining from prescribing medications they preferred to use due to prior authorization requirements — or even the expectation of having to complete one. That means many psychiatrists may be prescribing medications they don’t feel are the best choice for their patients.

To be sure, we also saw evidence of psychiatrists going to bat for their patients. When they opted to prescribe medications requiring prior authorization, almost half at least occasionally changed their patients’ diagnosis to one allowed by insurers so those patients could get their medication covered. With so many psychiatrists forced to resort to this shady tactic, it’s obvious something is wrong with the prior authorization system.

The American Medical Association and other professional organizations are focusing more and more attention on improving prior authorization, proposing solutions like automating the process, reducing the number of medications requiring prior authorization, and retiring prior authorization requirements on medications for which requests are almost always approved. New state and federal legislation designed to streamline the prior authorization process and control prescription drug prices are essential to implementing such interventions, but progress on those fronts has been glacial.

Until such legislation is passed, though, providers and patients will continue to find themselves caught in the crossfire between pharmaceutical companies, pharmacy benefit managers, and insurers. This leaves providers with tough decisions to make about whether to treat patients with the medications that insurers prefer or advocate for the ones we think would be a better fit. Increasingly, we have no choice but to undertake the prior authorization process for our patients’ sake.

And that means less time with our patients and more time navigating yet another bureaucratic maze in our quest to provide patients with the safest and most effective care possible.

Brian Barnett is a psychiatrist at the Cleveland Clinic and assistant professor of medicine at Case Western Reserve University School of Medicine.