As medical improvements proceed to rework affected person care, physicians have discovered themselves caught in an more and more irritating tug-of-war with insurers over entry to cutting-edge improvements with sufferers being caught within the center. Initially put in place to assist comprise health-care spending and curb pointless companies, prior authorization insurance policies are creating pointless boundaries and delays to wanted care, negatively impacting affected person outcomes, and driving up prices in the long term.
In keeping with a 2022 survey performed by the American Medical Affiliation (AMA), 94 p.c of physicians mentioned the prior authorization course of delays entry to obligatory take care of sufferers.1 Simply as regarding, 86 p.c of physicians reported that prior authorization necessities lead to elevated use of healthcare assets, resulting in waste and purple tape delays as a substitute of the associated fee financial savings that insurers declare the method helps create.1
Whereas prior authorization hasn’t modified a lot, the medical improvements obtainable to sufferers have grown significantly. As a urologic oncologist, I take advantage of high-intensity targeted ultrasound (HIFU), also called targeted ultrasound remedy, to deal with sufferers battling prostate most cancers. This process makes use of ultrasound power to noninvasively destroy cancerous tissue within the prostate with much less danger than surgical procedure or radiation, and fewer life-altering negative effects like erectile dysfunction or urinary incontinence.
Sadly, burdensome prior authorization necessities presently restrict the uptake and adoption of this process and lots of different kinds of rising, revolutionary applied sciences. Like many docs, I work carefully with my sufferers to establish a course of remedy that’s most acceptable for them. Unsurprisingly, my sufferers more and more favor a much less invasive HIFU process to keep away from the negative effects and dangers of radical surgical procedure.
By the point prior authorization requests for these companies are submitted, each my affected person and I’ve come to the choice that HIFU is the most secure, most useful choice for them. Ideally, that must be the top of debate. Insurers mustn’t intervene within the selections made between docs and sufferers.
This isn’t the case. Only in the near past, BlueCross BlueShield denied a previous authorization for considered one of my sufferers whom I used to be planning to deal with with HIFU remedy. Within the denial, the insurer claimed that the process is “unproven and investigational,” a declare that flies within the face of years of medical and scientific literature citing the success of targeted ultrasound.
By limiting my sufferers’ entry to applied sciences like HIFU, insurers are taking the apply of drugs out of my fingers. With out having these HIFU remedy choices in our remedy arsenal, suppliers are left with fewer choices — ready anxiously because the most cancers grows or turning to aggressive radiation or surgical procedure that introduces pointless complexity to the remedy course of.
As physicians, we should hold the stress on insurers to reexamine their insurance policies relating to HIFU and different rising applied sciences. One profitable technique, as time-consuming as it’s, is to observe via with the prior authorization attraction course of.
At the moment, there’s little pushback in opposition to prior authorization necessities, permitting insurers to proceed to aggressively abuse the system. For instance, solely two-tenths of 1 p.c of sufferers enrolled within the ACA market filed an attraction in 2021.2 In the identical 12 months, there have been two million prior authorization denials in Medicare Benefit.3 Whereas solely 11 p.c of these had been appealed by physicians, over 82 p.c of these appeals had been in the end authorized. Within the quick time period, this will create further administrative work, however the shockingly excessive success price of prior authorization appeals makes it greater than definitely worth the effort for sufferers.
As medical innovation continues to extend the instruments physicians have at our disposal, it’s essential for suppliers to push payers to broaden entry to the most recent, best FDA-approved applied sciences. Within the meantime, we should proceed to navigate the cumbersome prior authorization course of, together with interesting denials. Taking this last step to persuade insurers to cowl new procedures like HIFU remedy is probably going simpler than it appears and may very well be a significant approach to broaden entry to take care of our sufferers.
Dr. Frye is a urologic oncologist who presently serves because the Affiliate Professor of Urology and Vice Chair of Medical Affairs for the Division of Urology on the College of Rochester Medical Heart in Rochester, New York.
References
1. American Medical Affiliation. 2022 AMA prior authorization (PA) doctor survey. Obtainable at: https://www.ama-assn.org/system/recordsdata/prior-authorization-survey.pdf . Accessed Could 13, 2024.
2. Pollitz Ok, Lo J, Wallace R, Mengistu S. Claims denials and appeals in ACA market plans in 2021. KFF. Obtainable at: https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/ . Printed February 9, 2023. Accessed Could 13, 2024.
3. Biniek JF, Sroczynski N. Over 35 million prior authorization requests had been submitted to Medicare Benefit plans in 2021. KFF. Obtainable at: https://www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/ . Printed February 2, 2023. Accessed Could 13, 2024.
