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Orlando Sentinel: Health insurers’ prior authorization policies put profit before patient

Despite rising premiums, consumers still face greater insurance-company hurdles — like prior authorization requirements — when trying to access their health-care benefits. I know first-hand how prior authorization can disrupt treatment and endanger a patient’s health.

Politicians debating how to restructure America’s health-care system should restrict policies that pad insurance-company profits by reducing patient care.

Under prior authorization policies, insurance companies may not pay for a drug until the doctor has submitted lengthy documentation justifying the drug choice. Compiling documentation, sending it and waiting for review can significantly delay a patient’s access to vital drug treatments. In an American Medical Association survey, 69 percent of doctors said they waited several days for prior authorizations, and 10 percent reported waiting more than a week.

In my case, prior authorization delayed my access to a vital medication for an agonizing two weeks, during which my health was at risk. My physician prescribed Victoza for my Type II diabetes, which was effective and fully covered by my insurer. But when I had to transfer to a different company, the new insurer refused to pay for the medication until it evaluated my doctor’s justification, reviewed my treatment history and analyzed the impact on company profits.

The average retail price for Victoza is far outside my budget, at $921. Depending on the patient’s dosage, this can last from a couple of weeks up to three months.

I did not have enough time to apply to discount programs, so I ended up going without the medication for two weeks. Victoza, and other medications that manage blood glucose levels, do nothing to cure diabetes itself. When patients stop the medication, they also lose the blood glucose control that it was providing. Going without Victoza for two weeks risked that my glucose levels could spiral out of control from a single dietary slip-up.

My medication was ultimately approved; yet, I had to go through this entire process again with my new carrier not two months later due to the carrier’s “internal review policies.” This delayed my medication once again by two more weeks. Prior authorization puts some patients at risk that their treatment will be denied outright, even if the drug is listed on the insurance company’s formulary. Some prior authorization policies deny a medication if the doctor prescribes it for a purpose other than the condition for which it was created.

Whatever cost savings accrue from prior authorization come at the expense of doctors, who must spend more of their time combating insurers that second-guess their treatment choices. Each year, the average doctor spends more than three weeks total on the phone trying to obtain authorizations for their prescriptions and resolving billing issues.

A survey by the journal “Health Affairs” found that these interactions cost the average medical practice an estimated $82,975 per physician, per year — costs that either pass to patients or are absorbed by providers.

Insurance companies should not have the final say on treatment choices just because they hold the purse strings. Doctors spend years learning treatment protocols. They pass medical exams and stringent licensing criteria. That effort and expertise is invaluable when choosing a medication that is in the best interest of a patient’s health, even if not in the insurer’s best interest.

Lawmakers who are reforming health care should prioritize patients over profit, and restrict insurance companies from flexing their financial might to undermine doctors and delay treatment for patients.

Edith Gendron is the chief of operations for the Alzheimer’s & DementiaResource Center in Orlando.

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