Who authorized prior-auth anyhow?

Who authorized prior-auth anyhow?

By Sander A. Flaum, MBA, Principal, Flaum Navigators, Advisory Board Member and Executive-in-Residence, Fisher College of Business, The Ohio State University 

COVID-19 was and continues to be a nightmare. Not so much for healthcare insurers and payers, though. Humana, CVS Health, Anthem, and other players are raking in huge profits that have sent them to the top of the Fortune 500. Much of their bounty can be traced to the growing use of prior authorization (PA) to save money by postponing, and sometimes preventing, patients from receiving prescribed drugs and procedures. 

As frustrating as it is for a pharmaceutical manufacturer to see its breakthrough drug put on a restricted tier, PA is equally bothersome for doctors. As stated on the American Medical Association’s website: PA is a “cost-control process that requires providers to qualify for payment by obtaining approval before performing a service. It is overused, costly, inefficient, opaque and responsible for patient care delays.”  

Here’s an example. Last July, Aetna (owned by CVS Health) unexpectedly threw a monkey wrench into the lives of many thousands of people by demanding PA before covering any cataract surgery. Really – as if saving a person’s vision needed bean-counting oversight. It’s not as though cataract surgery is risky or controversial. Sure, a few decades ago, laser surgery and intraocular lenses were new technologies, but today these procedures are quick, painless, and amazingly effective. Insisting on routine PA simply makes the process harder for surgeons and patients alike.  

Want another example? Insurers routinely force doctors treating infections to begin therapy with the “tried and true” options – even though many of these drugs have long since lost their punch due to drug resistance. This is especially common with conditions such as skin and soft tissue infections. Before any “big gun” anti-infective can be used, the patient is forced to undergo a course of the generics. That’s profitable for insurers, but risky for patients. 

Pharmaceutical manufacturers know this story well. Discovering and developing a new antibiotic, antifungal, or antiviral that’s able to bypass resistance, kill target organisms, yet without causing serious side effects, is not only difficult, but also enormously expensive. Unfortunately, these wonder drugs are often money-losers, since insurers and payers routinely play the PA card to keep the brand on the pharmacy shelf. Does that make sense to you? Why should insurers stand in the way of infectious disease specialists choosing a therapy of their choice – especially if it’s one with the best chance of working?

Here’s an example that might not occur to many readers – unless they’ve been impacted. Since 2017, infertility has been classified in the United States as a disease, and a variety of treatments are available, with many new approaches on the horizon. Unfortunately, some insurers apparently think that infertility is a “life-style” problem or an inconvenience, like ED for a man. Perhaps that’s why they often refuse to pay for infertility treatments and, if they do offer coverage, they force patients to jump through hoops and then slap on huge co-pays. 

Using PA to delay access to treatment plays into the hands of those who clamor for a single-payer, government-run healthcare system. Whatever you think of Sanders, he has a point here. Healthcare in the United States is capricious – in large part due to insurers and their lack of transparency about premiums, coverage, and copays. If we don’t like the solutions advocated by Sanders and his allies, we in the healthcare industries need to make accessing treatment less painful and more equitable. A big step forward would be if insurers and payers focused on making sure that people get the treatments their premiums have paid for – without having to endure unnecessary procedural delays.