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"Prior authorization by insurance companies compromises patient care in a number of ways. Insurance companies must be held accountable for the medical decisions they make, just as physicians are accountable for the medical decisions we make."

My patient was upset as she informed me that she could not get her medicine.  Her insurance company had denied it again, because it needed prior authorization.  No big deal.  This happens a lot.  Except that this was a medicine she had been on for the last 6 years with good results, and this was the 4th time that she had to go without it, while waiting for her insurer’s approval.  I would have to write another letter of medical necessity to justify why she needed this medication, even though it had already been explained to the insurer three times previously.   So the question I pose, is why I have to spend so much time justifying the necessity for my patients care.

The corporate takeover of medicine has compromised the medical care that patients receive in many ways.  Insurance companies have a general distrust of physicians and often undermine their ability to make decisions as to what is appropriate care.  This goes along with the insurer’s desire to cut insurance expenditures.  One of the results of this distrust is prior authorization, a process whereby the insurer must approve an order for a diagnostic test or treatment before the patient can receive it.   This approval process often results in a delay or even denial of necessary treatment, and is determined by an insurer who has never examined or even spoken with the patient.

The prior authorization process starts with the physician’s office staff submitting information to the patient’s insurer regarding the recommended test or treatment. If care is denied, the physician must then write a “letter of medical necessity” justifying the rationale.  This is often followed by a “peer-to-peer” phone call, where the prescribing physician must convince an insurance doctor that the care prescribed is appropriate.  Most of the time, the “peer” is not a physician in the same specialty and often has no personal knowledge or experience of the issue at hand.  Instead, they typically follow “guidelines” that may apply to most people but may not apply to the individual patient.  It is classic cookie cutter, one size fits all health care.  Can you imagine going into Baskin Robbins and finding out they had gotten rid of 30 of their flavors because most people like vanilla.   This is where we are headed, to a place where population medicine rules and the individual patients’ needs are thrust aside.

Prior authorization can compromise care in many ways.  As an example, consider the case of my patient who presented with ankle pain.  Previous X-rays were negative, and I ordered an MRI to define the anatomy of the joint.  The MRI request was denied, so the next step was a peer to peer (with someone who was not a rheumatologist).  The insurance doctor told that my patient needed to do physical therapy before he could have an MRI.  When I asked her why, the peer told me, “Because some people get better with PT.”  I was incredulous.   I informed the “peer” that she was asking me to commit malpractice, and I was proven right when the MRI revealed an occult fracture.   The patient was placed in a cast and did well.  What would have happened if the insurance “guideline” had been followed?

Prior authorization not only detracts from care for the patient who needs it, but it also diverts physician care from other patients.  Time spent writing letters or engaging in a peer to peer is time that other patients in the office are kept waiting.  As it is, primary care physicians spend almost twice as much time on documentation as they do in direct clinical face time with patients, not to mention the extra 1-2 hours spent at home on documentation.

Insurers may also mandate needless preliminary tests that provide no useful information. Examples include plain films of the spine, when the concern is a herniated disk, or plain films of a knee when the concern is torn cartilage. These unnecessary tests result in delay of diagnosis and treatment for the patient, and wasted money for the third party payer.

Another way which prior authorization can harm patients is via step therapy.  Step therapy typically dictates that patients must try a preferred (less expensive?) drug first, even if the treating physician feels that the drug is less effective or not appropriate in the particular case.   If an insurer’s formulary changes, patients may be denied medicine they have taken successfully for years, in exchange for a new medicine that they have never taken.

 A 2019 survey by the AMA of 1000 practicing physicians revealed the following notable findings:

  • Physicians complete, on average, 33 prior authorization requests a week, requiring 14.4 hours to complete.
  • 86% of physicians report the burden of prior authorization as being high or extremely high.
  • 86% feel that the burden has increased over the last five years.
  • 43% cite this increase as being significant.
  • 91% report that prior authorizations result in delays in patient care.
  • 48% describe these delays as occurring often or always.
  • 74% of doctors note that patients may actually abandon care because of prior authorization.
  • 24% report that prior authorization has led to a serious adverse event in their patients with 16% reporting that prior authorization has resulted in hospitalizations.
  • 90% of physicians feel that prior authorization negatively impacts patient care.

Interestingly, this issue made headlines in 2018, when a former medical director for Aetna in California admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care.

It is one thing if insurance companies make decisions care based strictly on financial considerations.  If they determine that a medicine is too expensive and they will not cover it under any circumstances, that is their right.  However, as soon as the medical facts of the case become part of the decision making, the insurer is then practicing medicine, even though they have never evaluated the patient themselves.

There needs to be a better system for peer to peer discussion/ insurance “approval”.   I have suggested the following to any legislator who will listen.

  1. Insurance guidelines must not be mandates, to be blindly followed regardless of circumstances.
  2. Peer to peer discussions should always involve a physician in the same specialty.
  3. Denials must have specific rationales. Tests or treatments should not be denied simply because, “That is what the guidelines say”.
  4. The insurer should offer appropriate alternatives when care is denied.


Most importantly:

5. Insurance companies must be held accountable for the clinical judgments they make. Decisions made by insurance companies based on clinical data such as a peer to peer discussion, are medical decisions, and should be held to the same scrutiny as medical decisions that practicing physicians make every day.

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Mark Lopatin

Rheumatologist, author, trustee for the Pennsylvania Medical Society Board of Directors, health care advocate


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