Modern medication has the ability to save lives and improve living standards. However, medicine is less beneficial when patients’ prescribed treatments are delayed, and entirely ineffective when patients forgo treatment altogether. Many people in the US have trouble accessing the medication that they’ve been prescribed. This happens for various reasons, including price barriers and pending prior authorization from insurance companies.
Medication affordability is a hot topic in the US. According to an article on Harvard Medical News, the price of medicine can be so prohibitive that millions of adults throughout the country skip their medication. A survey from the National Center for Health Statistics reported that 8% of US adults don’t take their medications because they aren’t able to afford them. This 8% isn’t evenly distributed— among adults under the age of 65 with insurance, the statistic falls down to 6%. Conversely, 10% of people with Medicaid and 14% of people without insurance altogether skip medications due to price. Another story from CNN expands on the issue of price. It discusses a West-Health Gallup survey from April 2019 that estimated that adults in the US had borrowed $88 billion dollars in the past year to afford health care. The survey reported that one in eight adults had borrowed money in order to pay for the otherwise prohibitive cost of their care.
Other patients are left waiting for treatment because of another obstacle: prior authorization. This issue is highlighted in a story from The Morning Call. The article discusses how Pennsylvania doctors and legislators are in the midst of a political struggle to change regulations surrounding a common health insurance company practice called ‘prior authorization.’ In this process, an insurance company will ask your physician to obtain approval for the medication they want to use to treat your condition. In these circumstances, prior authorization must be completed before the health insurance company will cover your medication. Ideally, this authorization should take no longer than a week, but this isn’t always the case. Unfortunately, in some cases, even a delay of a few days could have a major impact on a treatment’s effectiveness; for some, even minor delays can turn into a life or death situation.
The reasoning for measures like prior authorization is that they can reduce overall costs for the insurance company. Companies want to double check that your medication is economical, medically necessary, and isn’t being duplicated. There are several circumstances in which a company might require prior authorization, such as when using a particularly expensive medication, a “name brand” medication that has a generic alternative, a drug for non-life threatening conditions, a drug deemed medically necessary but not typically covered, or for unusually high doses. While prior authorization is important for keeping costs low for health insurers, the fact remains that it can result in delays in treatment.
This is why some Pennsylvania physicians have grown frustrated with this process as navigating patient care has become more difficult as they work to overcome gaining access to the treatments needed for their patients.
Dr. Jonathan Garino, the VP of the Pennsylvania Orthopaedic Society, says that “excessive, inconsistent and unnecessary” use of prior authorization by insurance companies has created a system that “is designed to delay or deny care.”
Dr. Mary Stock Keister, President of the Pennsylvania Academy of Family Physicians, reported that her organization’s survey revealed that in 98% of cases, the use of prior authorization caused a patient treatment delay. She went on further to state, “Patients deserve the right care at the right time, determined by their physicians, not by insurance companies”.
A proposed bill in the Pennsylvania legislature to remedy this situation and expedite patient access, seeks to require insurance companies to use a standardized, online authorization process and would also require them to cover the treatment if it otherwise passes authorization. New regulations surrounding prior authorizations haven’t been implemented in at least 20 years in the state.
While managing prior authorizations is one challenge patients face, we know that there could be any number of difficulties one might encounter when trying to access needed medication. Have you needed to get access to a new treatment from your doctor recently?
Acknowledgment: This story is sponsored by Snow Companies and is promoted through the Patient Worthy Collaborative Content program. We only publish content that embodies our mission of providing relevant, vetted and valuable information to the rare disease community.