Writing for Kaiser Health News, Bram Sable-Smith describes his struggle to access insulin, a diabetes medication he needs to stay alive, while he waited for a prior authorization to go through with his new insurer.

Infographic: 5 ways to control the flow of drug expenditures

Running out of time and insulin

Sable-Smith, who has Type 1 diabetes, requires insulin to stay alive. But the day before Thanksgiving, he received a voicemail from his pharmacist in Wisconsin telling him that his insurance refused to cover the medication. At that point, he had 17 days' worth of insulin left.

When Sable-Smith called a pharmacist in St. Louis, where he had recently moved for work, about his insulin issue, he was told that his new employer-provided insurance would not cover the medication without prior authorization. Without prior authorization, Sable-Smith would be responsible for the list cost of the medication, which was $339 per vial.

Because Sable-Smith had not yet been able to meet with an endocrinologist in St. Louis, his best option was to call his previous doctor's practice on Monday morning and "beg" the staffers there to fill out prior authorization forms for him, even though he was no longer a patient.

Over the next few days, as his insulin supply continued to dwindle, Sable-Smith fielded several calls with the pharmacy and his old doctor's office in hopes that the prior authorization for his medication had gone through.

On Friday, with one day of insulin left, Sable-Smith writes that he began looking for alternatives online, such as a manufacturer-run program for less expensive insulin. However, before he could try that program, he received a call from a pharmacist who said his insurance would cover insulin, but under a different brand than he was currently using.

Even then, Sable-Smith had to go to three different branches of the pharmacy chain before one had enough of the medication to fulfill his prescription. "With 12 hours' worth of insulin left, I walked out of that third store with my medicine in hand," Sable-Smith writes. "It took 17 days and 20 phone calls."

Is prior authorization a benefit or a burden?

For the insurance industry, requiring prior authorization for certain treatments helps increase patient safety and save money, Sable-Smith writes.

"Prior authorizations are in place to protect patients, to improve safety and to try to make sure that the care they receive is as safe as possible and also as affordable as possible," said Kate Berry of America’s Health Insurance Programs (AHIP).

However, most physicians have the opposite view, as many say it is a burden to them and their patients. In a 2019 survey from the American Medical Association (AMA), 91% of the 1,000 respondents said prior authorizations "have a negative impact on patient clinical outcomes," and 75% said they "can at least sometimes lead to patients abandoning a recommended course of treatment."

"In my practice, we have five individual physicians, and we hired five full-time employees whose primary duty is obtaining prior authorization and dealing with insurance companies," said Bruce Scott, an otolaryngologist and speaker of the AMA House of Delegates. "Prior authorization is a burden on providers and diverts valuable resources."

According to Scott, AMA doesn't expect insurers to completely get rid of prior authorization requirements, but it believes the requirements "should be focused and ... better planned."

Separately, Scott Isaacs, a member of the board of directors for the American Association of Clinical Endocrinologists (AACE), said physicians in some specialties should not be subjected to prior authorization requirements. "[AACE] feel[s] that physicians [who] are specialists in endocrine disease should not be required to fill out prior authorizations for endocrine treatments," he said. "It's a huge burden for the patients trying to get this sorted out. Sometimes it's red tape; sometimes it's a true denial. It's a huge burden for the doctors as well, and the doctors resent it."

In general, both physicians and insurers have acknowledged there are ways to improve the prior authorization process. In January 2018, AMA, AHIP, and other industry stakeholders released a consensus statement, which outlined five areas where the prior authorization process could be improved. (Sable-Smith, Kaiser Health News, 1/25; Sable-Smith, Kaiser Health News, 9/24/19)