Physicians Say Health Plans’ Prior Authorizations Distract Doctors, Cheat Patients

More than nine out of 10 doctors recently surveyed reported that prior authorizations have had a negative impact on patient clinical outcomes, but psychiatrists are especially impacted by this burden posed by insurance companies.

Health plans and benefit managers contend that prior authorization requirements are needed to control costs and ensure appropriate treatment. But in psychiatry, patient advocates say these requirements are a way for health insurance plans to supplant the role of the psychiatrist, circumvent mental health parity laws, and cheat patients.

Among psychiatrists, prior authorizations are common when patients switch psychiatrists or health plans, after they have been treated for a certain number of visits, when their medication type or dosage prescribed is changed, and when they are prescribed an expensive name-brand or off-formulary drug. Other significant problems include prior authorization criteria that do not allow for clinically based exceptions, especially regarding step therapy requirements and continuation on the same drug or drugs after hospital discharge. The Trump administration has proposed a rule that would substantially increase the use of prior authorization for psychiatric drugs in Medicare Part D plans.

When prior authorization requirements are imposed, less than one-third of patients end up with the originally prescribed medication—and 4 out of 10 patients end up abandoning therapy altogether, according to a report by PharmExec. Every week a medical practice completes an average of 31 prior authorization requirements per physician, using nearly two business days of physician and staff time to complete, a recent survey of 1,000 physicians by the AMA found.

Psychiatrist Elie Aoun, M.D., said he sometimes must wait on hold for more than an hour to secure prior authorization approvals from an insurance company. In psychiatry, medication options are relatively limited, he said. “It adds a lot of hurdles. We’re fighting so hard to access treatment for our patients,” he said. When he finally gets through, he is “speaking to a representative with no clinical training or experience who is just going through a checklist.”

The AMA’s survey found that more than one-third of physicians employ staff members to work exclusively on prior authorization tasks. Like many psychiatrists, Aoun has had to subscribe to a monthly service to help him manage the myriad prior authorization forms. “It’s absurd that we’re paying a service to help our patients receive the medications we’re prescribing for them.”

“Basic medical services in other specialties don’t require prior authorization, but in psychiatry, they do,” said Jacques Ambrose, M.D., chair of the APA/APAF Leadership Fellowship and a clinical fellow in child psychiatry at Harvard Medical School and Massachusetts General Hospital. “For example, if a patient with chronic heart disease needs to be hospitalized for monitoring, it’s no problem. In psychiatry, if a patient with suicidal ideation needs to be admitted for monitoring, suddenly prior authorizations are needed.”

Psychiatric patients from lower socioeconomic classes are more greatly impacted by prior authorization denials and other utilization management practices because they are not able to pay out of pocket or seek care elsewhere, Ambrose said. “In low-income clinic settings, the level of care is drastically limited. If I’m able to prescribe only medication X, Y, and Z, what does that mean for my patients? It’s very unfair for already vulnerable populations.”

Part of the problem is that there is no government agency that regularly monitors prior authorizations or investigates complaints about them, Ambrose pointed out. “There’s a lack of transparency about the process, too, which allows insurance companies to dictate care.”

APA is a member of the AMA’s prior authorization coalition, a group of some 17 medical societies focused on reducing the negative impact that utilization management has on providers, patients, and the health care system. The coalition is working to encourage health plans—as well as the organizations that provide them with accreditation—to adopt their reform principles, which focus on clinical validity, continuity of care, transparency and fairness, timely access, and administrative efficiency.

APA and its district branches, along with other state medical organizations, have had some success tackling a related utilization management process deployed by insurance companies known as step therapy, also called “fail-first” practices. In January, Ohio became the latest state to sign step therapy reforms into law, joining at least 18 other states.

Pharmacists don’t typically advise patients when prior authorizations pop up that they can purchase their medications “out of pocket”; rather, they are simply told their insurance plan “denied” their prescription, said psychiatrist John Bailey, D.O., who is a Florida Psychiatric Society Assembly representative and member of the Florida Medicaid Pharmaceutical and Therapeutics Committee. “Within the past month, I’ve had patients who were told that their insurance company denied their sertraline, so they stopped taking it rather than calling me. They were so surprised on follow-up when I told them they could have bought the medicine outright for about $10 a month.”

Bailey said the prior authorization process makes for a “dangerous distraction from providing safe medical care,” taking up to two to three days at times to secure an approval. “There is no way for a physician to spend two to three days persistently pursuing a prior authorization for a single patient’s medicine—and to also keep up with the many other responsibilities of providing care to other patients.”

“Because of the insurance company practices,” said Aoun, “we end up adapting the type of care we are providing to our patients. Rather, it should be the other way around.” ■