On October 30, MAFP staff and members joined patients and colleagues from Michigan State Medical Society, Michigan Association of Osteopathic Family Physicians, and other healthcare organizations in downtown Lansing on Health Can't Wait Action Day to advocate for prior authorization and step therapy reform.
Among those in attendance were Ashley Wieczorek, DO, and Jessica Gibson, DO, who took time away from their duties at McLaren Health Care/Bay/ Michigan State University Family Medicine Residency to travel to Lansing.
“Health Can't Wait Day was an important day for many reasons. We went to meet with lawmakers to voice our concerns for not only our patients, but for co-residents’ patients as well. As family medicine residents at McLaren Bay Region, we handle all of our own medicine prior authorizations and see first-hand how it affects workflow, physicians, and most importantly the patients,” said Dr. Wieczorek.
Prior Authorization Delays Care
During discussions with lawmakers, Drs. Wieczorek and Gibson shared real-life examples of how physicians too often hit road blocks as they navigate insurers' non-standardized prior authorization requirements, which may change at a moments notice, while trying to deliver the care patients need. This, they said, results in care delays that not only cause health problems, but can increase medical spending as patients are forced to seek other alternatives.
"Currently, one issue with prior authorization is that there is no required turn-around time," Dr. Wieczorek told lawmakers. "I have patients who have waited weeks to hear of approval, or not, on a medication. One patient is diabetic and awaiting approval for a GLP1 agonist. It has been five weeks and counting since the initial prior authorization was submitted, and she is still without the medication. A medication known for its cardiovascular protection and glucose lowering abilities. A medication that is within guidelines to be added when a patient fails solely metformin."
Dr. Gibson has also found the process to be cumbersome and limits what physicians are able to do for their patients.
"Sometimes we are even unable to do evidence-based, standard care," she said, explaining that she is most frustrated when she has to fill out prior auths for "items that are on formulary as a covered benefit but the insurance companies won't pay unless we fill out a prior auth ... that we know is going to get approved. What a waste of time for everyone."
One example she shared is of a patient with type 2 diabetes, failed metformin, for whom she ordered a standard of care second line that required prior authorization. "I sent it in, but they needed proof of documentation. I then had to get fill records from the pharmacy, send in records including A1C for a medication that is preferred and listed as covered on the patient's formulary. It ultimately took almost three months for that patient to get her medication, putting her at continued risk for kidney disease, heart disease, and blindness, among other preventable conditions," she said.
Dr. Gibson shared that she has also received prior authorization denials for treatments whose costs are far less than the long-term complications they will avoid.
"I have a type 1 diabetic child who refuses to check his glucose by poking himself four times daily to allow appropriate insulin titration. He was, however, agreeable to do a continuous glucose monitor. I filled out the prior auth, sent in all the records. Denied. I called for a peer-to-peer appeal and was given the run-around on three different occasions. I never did get to talk to a physician or any medical provider, for that matter. The prior auth was ultimately left as denied after three months of fighting. Consider the cost of that CGM versus the long-term complications of severely uncontrolled diabetes ... all putting this child at risk for heart attack, kidney failure, blindness, coma, death."
Prior Authorization Leads to Serious Adverse Events
According to a 2018 American Medical Association survey, 91% of physician respondents reported care delays associated with prior authorization, 75% said it can lead to treatment abandonment, and 28% acknowledged that prior authorization has led to a serious adverse event for a patient in their care.
Case in point is the story Joan shared with lawmakers during Health Can’t Wait Action Day legislative visits. Joan’s husband consulted his family physician complaining of returning pain in his neck, shoulders, arms, and hands, associated with an injury he incurred over a decade before. His physician ordered an MRI, only to be denied by the insurance company. Months later, Joan’s husband awoke one morning to paralysis. Then, and only then, did the insurance company grant permission for the MRI, which revealed surgery was needed to decompress his spinal cord and fuse his neck with a titanium plate and screws.
“It should have never happened this way. Had my husband’s primary care doctor been allowed to order the MRI when these symptoms first started to reappear, they could have addressed the issue surgically before things got so bad. He would have never had to spend a full year off work and on disability. Prior authorization almost cost my husband his life,” said Joan.
Health Can't Wait Needs Your Voice
It is stories of delays and refusals for not just life-saving measures like these, but also common, everyday treatments and medications that ultimately end up being approved over 90% of the time, that are the driving force behind the Health Can’t Wait coalition’s push for reform. Patients deserve better.
“Our visits with the lawmakers were important to us to be able to share the stories of our patients and how prior authorizations are affecting their lives,” said Dr. Wieczorek.
Your voice, and the voices of your patients who have been adversely impacted by insurers’ prior authorization and step therapy requirements, are needed!
Educating lawmakers with facts and data is essential; however, it is the stories of patients and lawmakers’ constituents that will have the greatest impact to catalyze change. Stories are being collected at healthcantwait.org, Or, share your story with MAFP staff by emailing email@example.com or calling 517.347.0098.