Like many people, Lyndsey Crosbie would occasionally take Advil for pain relief. Unlike many people, it took two visits to the emergency room before Lyndsey and her physician realized that was a bad idea.
“It turns out I was actually allergic to NSAIDs and acetaminophen, which I would occasionally take to manage discomfort brought on by endometriosis and a painful hip condition,” said Crosbie. “Taking those medicines would cause me to break out severely in hives.”
The solution then was simple: Lyndsey would be prescribed a new medication as a replacement for NSAIDs, one that does not typically cause allergic reactions to those with NSAID allergies.
Her insurance company denied the new prescription.
“At the beginning of all this, I just had to pay out of pocket while waiting for my doctor and insurance company to clear things up. It wasn’t cheap—probably about $25 dollars for 15 pills—but I was in pain and it was all I could do.”
Thankfully, Lyndsey’s physician was able to get the issue resolved in short order. But the relief was just temporary.
“About a week later, I received a letter from my insurance company informing me I had to try about 10 other prescriptions for my pain relief before they would cover my prescription, and every one of them was an NSAID! I’m like, ‘Did you guys even pay attention?’”
It’s a story that reads like a Joseph Heller novel—a Catch-22 that seems too ridiculous to be real.
But it is.
Lyndsey’s story is all too real, and one that’s too familiar for a lot of patients here in Michigan. It’s a tale about prior authorization, step therapy and the wedge insurance company practices create between physicians and the patients they’re trying to help.
It’s not all bleak though. Michigan physicians, patients and patient advocates have banded together and found a better way forward. There’s only one thing left to do: convince lawmakers they’ve got it right.
Senate Bill 612, currently being considered by the Senate Health Policy and Human Services Committee, introduces new transparency and clinical validity requirements that would protect patients from costly and dangerous delays in access to health care, ensuring stories like Lydney’s become a thing of the past.
The Mechanics of Prior Authorization and Step Therapy
According to insurers, prior authorization and step therapy are protocols used simply to ensure patients receive the medicines, treatments and therapies that are the most safe and appropriate given an individual’s condition and circumstance.
In other words, insurers say they are looking out for what’s in the best interest of patients, and prior authorization and step therapy are the mechanisms that enable that watchful and caring eye.
Patients and providers alike see it differently.
“It’s all about controlling costs,” said S. Bobby Mukkamala, MD, president-elect of the Michigan State Medical Society. “With far too much regularity, insurance companies use prior authorization and step therapy to delay—and sometimes flat out deny—patients from accessing the treatments they’ve been prescribed. And the more expensive a drug or therapy is, the more likely it is to get caught up in the bureaucratic red tape.”
The stalling tactic may work as a cost-saving measure for insurance companies in the short term, but not before placing unnecessary administrative and financial burdens on the health care system as a whole—something that isn’t surprising given the rigmarole involved in seeing a prior authorization request through to completion. In the end, everyone—including insurers—pays the price. Up to 14 percent of U.S. health care spending goes to administrative costs incurred by private and public insurers, compared with an average of 3 to 10 percent in other developed countries. Burdensome prior authorizations contribute to that unfavorable disparity.
While each patient, case, and treatment plan may differ, the general process is always more or less the same. A patient with an illness or health challenge makes an appointment to see their physician. The physician examines the patient and then either diagnoses the problem and prescribes a treatment to address the issue, or orders the additional testing and screening needed to develop a diagnosis and a treatment plan.
From there, things often get complicated.
Insurers regularly require physicians to obtain a prior authorization for any prescribed or ordered medicines, treatments, and diagnostic procedures before agreeing to cover the costs associated with those measures, and that process is one that can be painstakingly arduous. Documentation requirements and procedures differ not only from insurer to insurer, but worse, from product and plan to product and plan, creating an unwieldy bureaucratic minefield. Successfully navigating the myriad of forms, formularies and requirements that come with a prior authorization requires a tremendous amount of patience, money, and most critically, time.
On average, physicians and their staff average almost two business days each week completing prior authorizations according to a 2018 survey from the American Medical Association. The Henry Ford Health System alone has a full-time staff of 100 employees devoted solely to processing prior authorization request. That all comes at an enormous cost. Prior authorization and step therapy practices’ costs to physician practices are estimated to be around $2,160 to 3,430 per FTE physician with total interactions with insurers costing $82,975 annually per physician, resources that could all be better spent on administering patient care.
And as exasperating as prior authorization can be for providers, the frustration felt by patients caught up in the process is undoubtably amplified. They face the same struggles in trying to navigate a maze of insurance company roadblocks while also going without the medicine and treatment they need. Often, the frustration is just too much, with an overwhelming 75 percent of physicians reporting that prior authorization can lead to treatment abandonment, according to a recent report from the American Medical Association.
“Unfortunately, it’s not at all uncommon for patients to walk away from a prescribed treatment plan because of all the hoops they have to first jump through in order to actualize it,” said Doctor Mukkamala. “Navigating prior authorization hurdles is often a time-consuming, confusing, and ultimately, extremely frustrating undertaking for patients. Faced with all of that, it’s not at all surprising that some just simply give up and opt to forgo the care they need.”
The Cost to Patients – More than just Money
Any decision to abandon care costs everyone—including insurers—in the end. As patients wait for the care they need, conditions worsen, health deteriorates and the cost of care skyrockets.
Doctor Mukkamala has seen it play out firsthand.
“A few months ago, I diagnosed a patient with tonsil cancer,” he said. “Thankfully, at the time of diagnosis, he was an excellent candidate for curative treatment because his cancer was localized and easily treatable with radiation following a biopsy. The diagnosis was made, and the treatment was lined up in a matter of days. But before being allowed to proceed, the patient needed a PET scan to look for the spread of any cancer.
“Getting approval for that scan took weeks, and in that time, the patient developed a lump in his neck. The cancer had spread in that three-week period. Now, instead of just radiation, my patient would also require chemotherapy.
“Had the requirements put in place by SB 612 been in place four months ago when I first diagnosed this patient, his current wellbeing and long-term prognosis would be much better today. Stories like these are not the exception. The delays brought on by prior authorization have gotten out of control.”
And there’s ample evidence to support Doctor Mukkamala’s claim. 94 percent of Michigan physicians report that prior authorization red tape causes delays in care for their patients. And the problem is only growing more pervasive, according to a recent survey from the American Medical Association, with 88 percent of physician respondents reporting that prior authorization burdens have increased over the last five years.
The problem has drawn attention from a wide array of patient advocacy groups around the state, with organizations like the Hemophilia Foundation of Michigan (HFM)—Michigan’s only nonprofit serving the bleeding disorders community through education, advocacy and supportive services—working to highlight and communicate the growing need for meaningful prior authorization reform.
“Hemophilia and other bleeding disorders are chronic and complex disorders that require lifelong treatment and specialty care to prevent and limit internal bleeding,” said Sarah Procario, advocacy and communications manager for HFM. “Timely access to appropriate therapies is a necessity for patients.”
However, with nearly all therapies for bleeding disorders requiring prior authorization, timely treatment and care is often out of reach for Michigan’s roughly 4,000 families living with the condition—a serious problem given the nature of hemophilia.
“Any delay in care can have a severe impact on their health. Even three days without treatment may result in additional doctors’ visits, hospitalization, and permanent injury from joint and muscle bleeds,” said Procario.
The regular delays are a concern for Procario and likely all the patients and families served by work of the Hemophilia Foundation of Michigan.
“The health of patients should come before cost considerations,” said Procario. “Prior authorization and step therapy have a role in health care, but they should never put the health and lives of patients at risk.”
Unfortunately, they often do. According to a recent survey by the AMA, 28 percent of physicians report that prior authorization has resulted in a serious adverse event including hospitalization, permanent disability and even death.
“Susan G. Komen is the world’s largest break cancer organization, funding more break cancer research than any other nonprofit, while providing real-time help to those facing the disease,” said Sarah Hockin, Mission Director at the Susan G. Komen Foundation of Michigan. “Komen served over 65,000 women and men alone in 2019. They were among the 1.3 million people diagnosed annually with breast cancer. Timely care can be the difference between life and death for many of them.”
Trudy Ender, executive director at the Susan G. Komen Foundation of Michigan, echoes the sentiment.
“We need to do better for these patients,” said Ender. “I can promise you that diseases like cancer are already stressful enough on their own. Making a patient wait and jump through hoops for a treatment or medicine with the potential to save their life is just simply wrong. It should not work that way. Every day—sometimes every hour—really matters.”
And what makes prior authorization such a difficult pill to swallow is that it’s almost always all for nothing. 97.5 percent of all first-time prior authorization requests are eventually approved. In other words, insurers are delaying critical access to care for essentially no reason.
Doctor Mukkamala sums the problem up nicely:
“The bottom line is that delays brought on by prior authorization are way more than just a hassle for our patients—they’re costing them their health, quality of life and sometimes even their lives. It’s a problem that needs to be fixed.”
The Solution
That effort has occupied physicians, patients and patient advocate groups—a formal coalition known as Health Can’t Wait—for nearly a year now.
Led by groups like the Michigan State Medical Society, Michigan Academy of Family Physicians, Michigan Society of Hematology & Oncology, Susan G. Komen Michigan, Hemophilia Foundation of Michigan and dozens of other physician and patient advocacy organizations, the coalition has spent months working to make policymakers understand the need for reform, and the introduction of Senate Bill 612 late last year is proof that their efforts are starting to bear fruit.
Introduced by Senator Curt VanderWall, Chairman of the Senate Health Policy and Human Services committee, SB 612 would do a great deal to rein in the devastating effects of prior authorization and “fail-first” procedures by empowering physicians to override step therapy protocol when appropriate and by implementing new transparency, fairness and clinical validity requirements to the prior authorization process, ensuring patients throughout the state receive timely coverage decisions, and ultimately, the care they need.
The legislation requires that insurance companies publish their prior authorization requirements on their website in an easy-to-find and easy-to-understand fashion. To ensure there is clinical validity baked into the prior authorization process, the bill establishes that adverse determinations and decisions on appeals must be made by a physician in the same specialty as the service being requested, while also requiring insurance company medical directors be licensed to practice medicine.
Perhaps most importantly, Senate Bill 612 would mandate that urgent and non-urgent prior authorization requests are acted upon within 24 and 48 hours respectively, which is what’s fair to Michigan’s patients in need of care.
“SB 612 is just sound policy,” said Doctor Mukkamala. “The modest reforms it enacts would have an outsized impact on Michigan’s patients and their health.”
That’s the message coalition members have been working to broadcast since the bill’s introduction, culminating in a series of hearings on the legislation earlier this year, with physicians, patient advocacy representatives and patients themselves coming to Lansing to offer testimony in support of Senate Bill 612.
Most speaking in support of the bill focused their time on sharing personal stories about themselves or patients whose health and wellbeing has suffered as a result of delays brought on by prior authorization.
Andrew Bade, a 20-year-old college student living with type 1 diabetes spoke before the committee about the consistent struggles he faces in trying to restock the equipment he regularly uses to monitor and maintain healthy glucose levels.
“I still feel like I can live a relatively normal life when I’m relying on the monitors and delivery devices my doctors have prescribed,” said Bade. “It’s when I don’t have them that things go downhill. Delays brought on by prior authorization regularly place a tremendous amount of stress on me and my family. Senate Bill 612 would do a tremendous amount to alleviate those worries for me and for countless others around the state battling their own diseases and illnesses.”
Lawmakers continue debating SB 612. In the meantime, physicians, patients and patient advocates can have an impact by sharing their personal stories about the negative effects of prior authorization and making their calls for reform heard, both of which are made easy by the Health Can’t Wait coalition.
“There are two ways you can have an immediate impact on our efforts to reform prior authorization,” said Doctor Mukkamala. “The first is to visit https://www.healthcantwait.org/share-your-story and share your personal story about the negative impact prior authorization has had on you, your family members, or your patients. These stories are powerful and help us communicate to lawmakers and the general public alike just how serious this problem is.
“Then contact your lawmakers and urge them to support SB 612. Visit https://www.healthcantwait.org/take-action and click ‘Take Action’ to get started. Sending the letter only takes seconds and lawmakers really do take notice. The voice of every constituent really does matter. When enough people speak up, change can and does happen.”