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The Effect of Prior Authorization on Clinical Decisions

Article Information

Stephen Salzbrenner*

Psychiatrist, University of Nebraska Medical Center, Nebraska, USA

*Corresponding author: Stephen Salzbrenner, Psychiatrist, University of Nebraska Medical Center, Nebraska, USA

Received: 09 March 2022; Accepted: 23 March 2022; Published: 04 April 2022

Citation:

Stephen Salzbrenner. The Effect of Prior Authorization on Clinical Decisions. Archives of Internal Medicine Research 5 (2022): 107-108.

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Keywords

Prior Authorization

Clinical Decisions articles

Article Details

It may seem intuitive to clinicians like myself, but prior authorization (PA), in its current state, signifi-cantly affects clinical decision making. If used as originally intended, PA can have a positive effect, including maximizing therapeutic value, ensuring safe prescribing, and containing costs [1]. PA can, for instance, steer a provider to a less expensive but equally effective medication or alert them to a signi-ficant contraindication. Both scenarios benefit the patient by improving their likelihood of treatment adherence and improved health. However, prior authorization requirements can also have a detrimen-tal effect on clinical decisions and patient health [2].

A 2021 NIH-funded nationwide survey of over 1100 providers revealed several ways prior authorization can negatively impact clinical decision. The findings of this survey will be submitted for publication this year.

These findings are critical for providers and patients alike. Providers may feel alone in their continued struggle to deliver optimal care in today’s healthcare system, a system that seems tragically designed to prioritize profits for insurance companies and pharmacy benefit managers (PBMs) at the expense of patient health. This can be quite demoralizing for well-intended healthcare providers who believe they have a sacred duty to deliver the best possible care to their patients. Patients may falsely believe that they are getting the best care available when in truth they are receiving what is most cost-effective but not necessarily their healthcare provider’s preferred treatment.  

This process, in a nutshell, strikes a tenuous balance between optimal care and maximizing profits. Patients frequently end up blaming their pharmacy or their provider for the long delays and/or high cost of medications. In reality, this is a trickle-down phenomenon that begins at the top with insurance companies and PBMs.

The purpose of this commentary is to assure providers that they are not alone in their struggle and to inspire patients to advocate for their health by reaching out to their pharmacy benefit managers, insurance companies and policymakers to demand reform in the prior authorization process. The study we draw on in this commentary included surveying physicians and advanced practice providers (APP’s) including nurse practitioners and physician assistants from nearly every state, representing a diverse range of practice sizes, and specialties including Derma-tology, Rheumatology, Oncology, Gastroenterology, Psychiatry, Family Practice, Internal Medicine and Neurology. Those specialties were chosen due to their relatively high rate of requiring prior author-ization when prescribing medications.

The survey will be submitted for publication this year and found that:

  1. Over a quarter of providers often modify diagnoses to avoid PA requirements.
  2. Over a third reported changing medications due to PA delays at least 30% of the time.
  3. Over two-thirds often avoid prescribing newer medications, even if evidence?based,

to avoid potential difficulties with PA.

For patients, this means there is a significant possibility that, due to insurance prior authorization requirements, a diagnosis in their medical record may be inaccurate and/or the medication being prescribed may not be the one that their provider would prefer. For providers, this means you are not alone in struggling, too often in vain, to provide optimal patient care in the context of unbearable requirements of time, effort and cost associated with the prior authorization process.

To change this broken process, providers and patients must contact their insurance companies, pharmacy benefit managers and policymakers and request that they improve this process to simplify the healthcare provider’s ability to prescribe the best treatment for the patient and assure that the process is capable of getting the treatment to the patient in a timely and affordable manner, even if the treatment may not necessarily be the most profitable for the insurance company or PBM.

References

  1. Hannan EL, Ryan LK, Van Orden RE. A cost-benefit analysis of prior approvals for medicaid services in new york state. Soci-Econ Plan Sci 18 (1984): 45.
  2. Barnett BS, Bodkin A. A survey of american psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis 208 (2020): 566.

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