Banner by Amy Zhang 

Prior Authorization: The Casualties of Insurance

By Zayaan Tirmizi

Nataline Sarkisyan, a 17-year-old girl from California, had recently been approved for a liver transplant operation that surgeons had deemed critical for her survival. However, her insurer, Cigna, refused to approve her transplantation procedure after she was diagnosed with a lung infection. Despite physicians pleading with the insurance company for approval and authorization for the procedure, Cigna only overturned the decision hours before Sarkisyan would die awaiting her transplant. Prosecutors alleged that the delay in approval for the procedure consequently killed Sarkisyan. Sarkisyan, however, is not the first, nor the last, of such cases. 

Insurance companies have stood as the longtime common enemy of physicians and patients across the American health care system. For decades, both doctors and their patients have often voiced complaints regarding the constraints that insurance companies place upon access to care and the quality of care patients receive. Chief among these complaints is the contentious subject of prior authorization. 

Prior authorization, or PA, is a regulatory procedure put in place by insurance companies requiring a physician to meet specific criteria before prescribing a medication, treating a patient surgically, or providing other clinical services. Insurance companies contend that PA regulations force physicians to practice “evidence-based medicine” according to the American Medical Association. For example, in order to undergo a certain procedure, a patient’s physician must prove to the insurance company that the procedure is indicated, or wholly necessary, for this patient. This evidence is usually obtained from the notes a physician charts during a specific visit in which they deemed a medication, treatment, or procedure necessary. Although seemingly harmless requirements at first glance, physicians argue that insurance companies have created unnecessary roadblocks that routinely delay care for patients. Problematically, the AMA found that 94% of physicians feel prior authorization leads to a delay in care, and 80% of patients eventually abandon care. Moreover, physicians dispute the argument that PA leads to evidence-based care, claiming that the criteria insurance companies provide often lack transparency or are not designed in manners that align with the clinical, evidence-based medicine they claim to enforce. Indeed, only 15% percent of physicians feel that prior authorization criteria are backed by evidence. 

The dispute is much more complex than simply physician versus insurance company. As is usually the case, the patient is the collateral. Prior authorization often adds significant time to the process of prescribing a medication or bringing a patient in for an emergent procedure. As a result, critical health care is delayed. In fact, in a study conducted by the University of Nebraska Medical Center, the inadequacies created by PA are detrimental. Approximately 91% of physicians reported that its requirements caused significant delays in care, and a staggering 90% reported that those delays resulted in noticeably worse patient outcomes. This is primarily due to the back and forth that occurs between physicians advocating for a drug for their patients and insurance companies forcing them to prescribe an often cheaper alternative. Physicians claim that insurance companies can take days to get back to them, and when they do, the request still gets denied. This puts the patient at risk by delaying their medication for a significant time, and can lead to major issues in access, particularly for vulnerable populations who are relying on immediate care. 

The numbers, however, do not effectively convey what these patients have endured. Debb, an Arkansas resident, explained her experience with PA to the American Medical Association, stating, “My husband went without blood thinners for two months because we switched insurance carriers...he could have had a stroke or pulmonary embolism, but the insurance company doesn’t care.” Many of these patients are on life saving medication for hypertension, diabetes, and other chronic conditions that require daily use of their medication, and any small delay can have dire health consequences. 

Doctors also argue that there seems to be an ulterior motive underlying the real reason why insurance companies are so adamant about prior authorizations. Maryland physician Matthew Mintz believes that “Prescriptions are expensive and prior authorizations are an easy way for insurance companies to save money.” The lack of transparency in the development of prior authorization policies only adds to ambiguity and lack of trust between providers and insurance as to the true intentions behind PA implementation. Rather than functioning cohesively, this rift between providers and insurance companies only seems to worsen. 

Undoubtedly, patients seem to brunt the majority of the weight in the status quo. The only solutions seem to be a transparent approval process of prior authorization policy, a more collaborative approach including physicians in prior authorization decisions, or the abolishment of it altogether. In any case, a pragmatic, and more importantly, quick solution is needed considering 16% of adult Americans have experienced prior authorization delays. With a country with such a large population, this translates to millions of Americans suffering yearly due to greedy insurance practices and preventing physicians from providing crucial care to a sizable portion of the nation.