An atopic dermatitis (AD) patient is forced to try and fail topical tacrolimus, pimecrolimus, and crisaborole, as well as an oral immunosuppressant, until—six months into this patient’s treatment—the insurer finally and begrudgingly agrees to cover the cost of the medication that the patient needs most.
What’s wrong with this picture?
For starters, the payer is requiring that an AD patient fail an unapproved oral immunosuppressive therapy prior to using dupilimab, which is FDA approved for AD. That alone is a head scratcher, but the patient is also forced to live with undertreated AD, a condition that has profound effects on quality of life.
Making matters even worse, the doctor’s team spent countless hours jumping through hoops to get the insurer to sign off on the drug that the doctor knew would end this patient’s suffering.
Sound familiar? It should. Medical practices report completing an average of 31 prior authorizations per doctor per week, which takes away around 15 hours of doctor and/or staff time that could be spent treating patients, according to a survey by the American Medical Association (AMA).1 In addition, delays from this process have led to serious consequences for patients who are waiting on approvals for medication, tests, or supplies. In fact, 83 percent of respondents to a new Medical Group Management Association poll said that prior authorization was “very” or “extremely” burdensome.2
The prior authorization process is maddening for patients and physicians, and we shouldn’t have to take it any more.
Broader Solutions Required
The good news is that the Centers for Medicare and Medicaid Services (CMS) agrees that prior authorizations are getting out of hand and is taking steps to rein in this burdensome process.
The bad news is that their current focus seems to be all about automation. CMS seems to be putting all or most of their eggs in one basket: the Da Vinci Project, a private sector initiative that is leveraging HL7 Fast Healthcare Interoperability Resources to improve data sharing in value-based care. The hope is that this technology will automate the prior authorization process across electronic health record (EHR) systems.
This is a good stepping off point, but such automation and the interoperability it promises may create additional hurdles. For one, manual review will still be necessary, which means that delays may still exist. If document exchange becomes easier and faster, it could mean more, not fewer prior authorizations. Moreover, payers will have access to EHR data, which could be used as a determining factor for coverage, unless proper safeguards are firmly in place.
The AMA, the American Academy of Dermatology Association, and the American College of Physicians are among 30-plus physician organizations that are calling on CMS to seek a broader solution.
Lack of transparency among payers adds to the burden associated with prior authorizations. We don’t know what requirements the various insurance companies have for approval. Greater transparency would mean standard clinical definitions for data elements and no more guesswork and mind reading. It would also be beneficial if CMS were to remove prior authorization requirements for services and drugs that focus on utilization or cost management, instead of clinical validity. Exemptions for clinicians who have a clear record of previous prior authorization approvals could also be a tremendous incentive, as well as a burden relief.
If and when such changes are enacted, the opening paragraph of this article may read something like: An AD patient comes in seeking treatment, is evaluated and started on the proper therapy within 24 hours, and comes back to the office for a follow-up visit with a meaningful reduction in the severity of eczema, a reduction in the body surface affected by eczema, and a smile on his face.
Fingers crossed that CMS will heed our collective call.
1. American Medical Association. “2018 AMA Prior Authorization (PA) Physician Survey.” https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf
2. Medical Group Management Association. “Annual Regulatory Burden Report.”