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Prior authorization: Valuable cost-saver or bureaucratic black hole?

Thousands of requests for prior authorization of prescriptions arrive daily in doctors' offices across the country, Danielle Ofri writes.
Thousands of requests for prior authorization of prescriptions arrive daily in doctors' offices across the country, Danielle Ofri writes. Christopher Furlong/Getty Images

Last month we heard from an Impatient reader who won a battle with his health insurer over its refusal to authorize a particular medication. But consumers aren't the only ones who find themselves yelling into the phone at a service rep -- your doctor most likely spends time doing it on his or her patients' behalf. 

In an op-ed in the New York Times, Dr. Danielle Ofri, an associate professor at New York University School of Medicine, writes that thousands of letters requesting a doctor's prior authorization for medication arrive daily in medical offices across the country.

She explains that insurance companies require prior authorization as a cost-saving measure: Doctors must provide a compelling reason why their patients need more expensive treatments, rather than less costly medications. She writes:

"In theory, this is a reasonable way to control costs by making it harder to prescribe costlier medications. In practice, it is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles."

Ofri gives us a glimpse into what it's like for doctors to navigate the health insurance system. She tells the story of the time she tried to authorize a medication for a patient who takes four different blood-pressure medications. It's a specific combination intended to treat his hypertension, diabetes, kidney disease, and valvular heart disease, she explains.

She recounts how she was bounced through phone trees and customer-care representatives, until the problem became clear: her patient's insurance would only cover 45 of the 90 pills he needs monthly. The representative asked if 45 pills would suffice.

Ofri describes her reaction:

"Are you out of your mind?" I hollered into the phone. "It's taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I'm going to randomly jiggle the dosages just for the hell of it?”

"A simple yes or no will suffice, doctor."

The current system – with its prior authorization requirements – doesn't benefit the patient or providers, she writes:

I'm all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient.

Doctors, is Ofri's story all too familiar? How much time do you spend getting insurers to authorize medications? What other parts of the insurance system frustrate you? And to patients: have you had trouble getting a medication authorized?

Tell us about it all – the positive, the negative, and the ordinary – in the comments section below, or e-mail us at Impatient@scpr.org.

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