*Prior Authorization’s Consequences for Patients* A big problem with prior authorization is that it creates confusion for patients about what is actually covered by their plan. When insurance companies make the coverage process unclear, it becomes harder for people to make informed choices about their healthcare. It’s one thing for an insurance plan to clearly state that it won’t cover a certain drug, but it’s entirely different when patients believe a medication is covered, only to be met with hidden barriers --- like overly complicated prior authorization forms that doctors must complete and submit, often by outdated methods like fax.
*Streamlining Prior Authorization* If a healthcare plan needs to verify whether a treatment is appropriate for a patient, much of the necessary information is often already available in the patient’s medical records. Ideally, insurance companies should be able to access this data and quickly make a decision, issuing a real-time prior authorization or denial based on the patient’s medical history.
For example, if a plan claims it covers CGRP migraine medications, but only for patients who have already tried and failed to benefit from generic drugs, the plan should be able to verify this through the patient’s medical records. If the records show that the patient has previously been prescribed these generic drugs, it should be sufficient to authorize the new medication. There’s no need for a long, complex form. After all, these drugs are prescribed to manage challenging conditions like migraines, which patients are unlikely to exaggerate or fake. If a drug doesn’t work, patients will stop using it --- there’s no incentive for them to undergo unnecessary treatments. So, what more could a plan need to know that requires such lengthy paperwork?
By simplifying the prior authorization process and using existing patient data, health plans can reduce delays in care and improve patient access to necessary treatments.
What we are advocating for is transparency, instead of opacity and friction. Only then can plans be judged in advance for the quality of their coverage, and the market can decide amongst them properly. Still for the most part, the market functions. So prior authorizations are something to try to optimize, but we aren’t saying that they have broken the healthcare system. In fact, for the most part, the healthcare system in America for medicines isn’t broken. Because if it were, you wouldn’t see the robust investment in the development of new medicines that we do.