These next two topics (abuse of prior authorization and denial of care) are related, and we’ll file them both under “insurers behaving badly.” It all boils down to denying care that a patient needs in order to save money for the insurance plan, and it’s wrong.
Prior authorization is a practice used by insurance companies to ensure that the medications prescribed by the doctor are appropriate for that patient at that time. This is largely done as a cost-saving technique to encourage doctors to use cheaper (often generic) treatments first, before trying the newest and most expensive ones. When prior authorization is automatic, electronic, and truly designed to guide patients to more affordable (but just as safe and effective) treatments or used as an added check on potentially dangerous therapies like opioids, it makes sense and it typically works.
But many prior authorization procedures are long and arduous, requiring doctors to advocate for their patients by convincing payors that the patient really does need the medication being prescribed. Doctors spend around 15 hours a week of their very limited time pursuing prior authorizations. Worse, this rigmarole can lead to substantial delays in getting medicines to patients. According to a publication from the American Hospital Association, more than 9 out 10 physicians say the prior authorization process has a negative impact on patient clinical outcomes. You can read the [OPTIONAL] report here:
This powerful video essay in the New York Times explores the grueling real-world impacts of care denials and delays.