According to a recent article in Statnews, providers must obtain prior authorization from an insurer for several reasons; to start, the insurer often requires physicians to justify prescribing a certain medication, procedure, or medical device that is more costly than the insurer’s preference.
There is also the matter of safety. Prior authorization is often required in order to cover increased dosing, length of administration, or frequency than the insurer deems appropriate.
These applications for renewal not only take place annually but in many cases several times each year. The process begins on January 1st. Due to the usual backlog, patients find themselves unable to renew their prescriptions and must either pay out of pocket or manage without their medication. Insurers will not cover many medications unless they are approved.
One doctor who was interviewed for the Statnews article questioned the process. He felt that he should not have to justify decisions that he made in the best interest of his patients. He opined that the prescribing was actually being made by people with no medical training and who only know his patients via computer screens.
The Way It Was
For years insurers would request prior authorization in an effort to discourage providers from using brand-name medications. The effort succeeded. Insurers primarily approved generic medications that were equally effective and less costly.
Recently prior authorization requests (including those for generic medication) have risen dramatically. But less expensive alternatives for generics no longer exist in some instances.
Each prior authorization request requires over an hour for the care provider to complete the application with its attached documentation.
Over eighty percent of prior authorization requests are actually approved. This brings into question whether insurers are benefiting from a reduction in costs accomplished through delayed prescribing. e.g. prior authorization backlog.
From the insurers’ point of view, prior authorization offers protection for patients against prescriptions that may be harmful to the patient.
However many providers claim to have witnessed prior authorizations that have been harmful.
How Prior Authorization Affects Psychiatry
Psychiatry is among the specialties that are especially affected by delayed prior authorizations. Most psychiatrists receive lower reimbursement for services rendered. In addition, many cannot afford administrative help to expedite authorizations. Delay greatly affects patients struggling with addiction and mental illness as patients have a tendency during the waiting period to discontinue or run out of their medication.
Other collateral damage includes an increase in emergency room visits for bipolar patients. People with schizophrenia are subject to frequent imprisonment.
And finally, there is the problem of opioid addiction. A delay in treatment for addiction can indirectly cause overdose and death (e.g. Suboxone).
A Survey of Psychiatrists
The national survey of psychiatrists indicated that prescribing behavior is often influenced by delays in issuing approvals for prior authorizations.
Two-thirds of respondents admitted that on occasion they would veer from their preferred medication to less attractive medication just to avoid authorization requirements.
Going a step further, some psychiatrists admitted to occasionally expanding their diagnosis to include the codes for medications requiring prior authorizations. The psychiatrists were confident that these medications would be covered. Some consider these tactics an indication that the system needs an overhaul.
The American Medical Assocition (AMA) and other groups are attempting to improve the system by reducing the number of medications that require prior authorization. The association has also proposed to limit prior authorization requirements for those medications that are usually approved.
State and federal legislation is being considered that would streamline the process and hopefully add controls to prescription drug prices.
But for now, providers must decide whether to prescribe medications that meet insurers’ criteria or medications that they believe are more suitable to their patients’ needs.
