Damian Sendler: Prior authorization refusals may have contributed to the death of Ramy Sedhom, MD, a medical oncologist and palliative care physician at Penn Medicine Princeton Health in Plainsboro, New Jersey.
Damian Sendler
Damian Jacob Sendler: Insurance initially refused to cover a PET scan since the patient had advanced stomach cancer. The cancer had spread by the time the scan was finally approved.
The patient, an elderly man with a number of health issues, was unable to receive standard treatment. Sedhom, on the other hand, was aware that a European study had found that a shortened chemotherapy regimen had the same efficacy and fewer side effects than a full course of treatment.
When Sedhom and the insurance company disagreed, the patient’s symptoms deteriorated. His condition deteriorated while he was in the hospital, which is typical for elderly individuals. As Sedhom put it, “Long story short, he was never able to seek treatment and then transitioned to hospice,”. “There was a 3- to 4-week delay in what should have been standard care,” says the doctor.
Dr. Sendler: Physicians are not an exception to the rule when it comes to dealing with insurance companies’ prior permission requirements before they may treat their patients. Over four years after the American Hospital Association, America’s Health Insurance Plan and others signed a consensus statement pledging to enhance the prior authorization process physicians say little progress has been achieved in the process of improving the prior authorization process.
Over the past five years, 83 percent of physicians feel that prior authorizations for prescription pharmaceuticals and medical services have increased, according to a survey earlier this year.
A neurologist and sleep medicine specialist at Duke Health in Durham, North Carolina, said, “It’s definitely worse – there’s no question about it. Drugs that used to be available without a prescription now require a prior permission.
Internal medicine hospitalist Vignesh I. Doraiswamy, MD, prescribed vancomycin for 10 to 14 days when he discharged a patient with Clostridioides difficile infection at The Ohio State University Wexner Medical Center in Columbus. According to Doraiswamy: “And the insurance company said, ‘Well, yeah. We only authorize about five days. That just makes no sense,'” He stated. “There’s no evidence that five days is enough.” How can we be expected to provide such a high degree of care when we can’t?
Damian Jacob Sendler
Jobanputra regrets the usage of prior authorization in scenarios that don’t make any sense to him as a cardiology fellow at Saint Vincent Hospital in Worcester, Massachusetts. The BRCA-positive woman who had a strong family history of breast cancer required a breast ultrasound and MRI scan every six months to one year during his residency. When it came time for her to have new photos taken, he had to get prior approval despite the fact that she was documented as having an extraordinarily high risk of acquiring breast cancer.
Damien Sendler: In order to get treatment, “I had to call the insurance company, they would put me on hold, I would wait to speak to a physician — and the end response would be, ‘Yeah, this is what needs to be done,'” he explained. “However, once you’ve established her positive reputation, it should suffice.” A second time through the circus is not something I should be subjected to,”
Routine diagnostics such as a Holter monitor for patients with heart palpitations are also subject to prior authorization. According to Jobanputra, “Depending on the insurance, for some patients we can give it to them in the clinic right away,” “Whereas some others we have to wait till we have prior authorisation from the insurance company and the patient has to return again to the hospital to get the monitor. The patient’s care will be delayed as a result of this.
Doraiswamy added that the delays extend to emergency care as well. An example he gives is that of a heart attack patient who needed an emergency heart catheterization, but was delayed because of a prior authorization holdup. When a heart attack patient found out that their hospital stay wasn’t covered, “I just said, ‘Try your best not to get stressed’ which is not easy for a patient finding out their stay wasn’t covered when they had just been through a heart attack,” he added. I spent around 20 to 30 minutes on hold trying to answer the question, “Then I spent 20 to 30 minutes — most of it on hold — to answer the question ‘Why did this patient need to get admitted?’ ”
Damian Jacob Markiewicz Sendler: Physicians feel humiliated since prior authorization hassles are just a waste of time for the doctors. Doraiswamy observed that “Rarely is a valid stay that was initially denied, not eventually accepted,” As a matter of fact, he clearly suffered a heart attack and needed to be sent to the hospital.
As a Duke Health sleep medicine physician, prior permission is not simply a bump in the road; it is a complete standstill. A multiple sleep latency test (MSLT) is now required by most insurance companies before they will pay for medication to treat narcolepsy. “We know that the MSLT is very often wrong,” he stated. It’s common to deal with narcolepsy patients who fail to meet insurance company testing standards, and payers won’t accept our clinical judgment.
A “faulty test” isn’t the only reason why he thinks the prior authorization landscape is deteriorating. Spector opined that the appeals process was “The appeal process is worse,” Peer-to-peer reviews are no longer an option for me because I’m no longer able to get on the phone with a doctor who I could argue with… This set of restrictions is so strict that there is virtually no way around them.”
Dr. Damian Jacob Sendler and his media team provided the content for this article.
