Prior authorization from insurance companies often delays treatment for patients.
By Drs. Jeff Vacirca and David A. Eagle
As doctors, we do our best to spend time with patients and make medical decisions that are best for their health. These days, insurance companies are making it increasingly difficult to do both. They have a process called prior authorization that basically asks, “Hey doc, do you really want to move forward with the plan and testing you just ordered?” The predictable answer is, “Well, of course, I do; that’s why I ordered it.”
In theory, prior authorization could serve as a valuable check to ensure the proper use of resources. However, if poorly implemented, it can create significant dangers and delays for patients in receiving the medical care they need — and that is the reality with insurance prior authorizations today. Fortunately, state legislation that would address this problem awaits only Gov. Kathy Hochul’s signature.
A recent American Medical Association survey found that 94% of doctors reported care delays due to prior authorization, 79% reported that patients abandoned treatment due to difficulties contesting prior authorization, and 28% of doctors said those delays led to serious or life-threatening adverse patient events. We can all agree that this is not the prior authorization system doctors and patients should face.
When patients are harmed by prior authorization, who is to blame? There are notable cases in which prior authorization has caused significant harm to patients, yet insurers aren’t held liable. How can an insurer get to deny care and essentially make medical decisions but have no true responsibility? Doctors certainly do not have this privilege.
New York's legislation addresses a particularly problematic aspect of the prior authorization process known as clinical peer review. After getting a denial for a planned test or therapy, doctors often get on the phone with the insurance company doctor to discuss the case.
As oncologists, we find that these peer-to-peer calls are a dangerous roll of the dice for patients with cancer. It is exceedingly rare that we speak to another doctor with direct training in cancer medicine. Instead, we are left trying to convince someone who doesn’t know how to treat cancer, nor the latest cancer medications, and has never seen our patients or sometimes even reviewed the records. Not only is this insulting, but it’s dangerous for patients with cancer.
Progress in cancer is exploding. Keeping up with scientific advances and new treatment options is an immense challenge for oncologists but worth it for our patients. Approximately 40% of new drugs approved by the FDA are cancer drugs. Patients with advanced cancers can now live for years due to recent advances in chemotherapy, immunotherapy, and targeted therapy.
High-quality cancer care decision-making involves detailed literature review, consultation with colleagues, and case review at regular cancer conferences known as tumor boards. Unfortunately, many New York health insurance companies are not similarly committed to ensuring patients benefit from the latest cancer treatments.
The legislation passed by the State Legislature requires that insurance company physicians be licensed in New York and trained in the same or similar specialty as the case under review. This is not a high standard but begins to place minimum requirements on physicians deciding the fate of patients with cancer and other serious diseases. We hope Gov. Hochul signs the bill into law — to protect patients and improve the quality of care delivered by professionals that serve them.