In Washington, a fight over the Kafkaesque absurdity of insurance delays, denials


In the two months it took the insurance company to approve drugs for Washington psychiatrist Jacob Swartz\’s patient, he saw how students, once regulated by ADHD and impulse control, unraveled: When and B they turned downvotes, they were suspended, their self esteem plummeted.

While Swartz could see the price of delay, the fate of the child\’s well-being rested with someone who had never spoken to them, a growing trend faced by patients and doctors as insurance companies eager to cut costs sought more influence in decisions. therapeutic.

Swartz was among several medical professionals who this week pleaded with a DC Council committee to join lawmakers across the country who want to regulate the practice, known as prior authorization, which insurers use to determine whether a drug or procedure is necessary medically before agreeing to cover some or all of this.

While insurance companies say a relatively small percentage of drugs and services require approval, critics, including the American Medical Association, say prior authorization is abused, costs providers time and money, and delays treating patients. with mental and substance use disorders who are vulnerable to relapse if treatment is interrupted.

The bill introduced to the DC Council, introduced by Brooke Pinto (D-Ward 2), would set deadlines for insurers to respond to prior authorization requests and appeals, allow denial only by a district licensed physician in the same specialty as the patient\’s physician, make approvals that last at least one year, and honor approvals for 60 days when a patient changes plans.

Reform bills are being considered in 30 states this legislative session with at least a dozen still pending approval, according to the AMA.

Last month the Biden administration revised prior authorization requirements for Medicare Advantage, private seniors insurance plans paid for with federal funds. United Healthcare\’s decision this year to require prior authorization for many colonoscopies has drawn national attention to the issue.

On Wednesday, Kris Hathaway, vice president of state affairs at Americas Health Insurance Plans, a trade association of health insurance companies, said in testimony to the council\’s health care committee that prior authorization, used in limited circumstances, helps patients to reduce costs out of pocket, prevent overuse of unnecessary or harmful care, and ensure services are consistent with evidence-based practices.

He acknowledged that the process can be cumbersome and said companies are working hard to direct the practice to high-tech imaging, elective services and specialty drugs.

Hathaway and insurance company executives were outnumbered by supporters of the measure who scoffed at the practice\’s impact on care in the testimony of patients whose fragile recovery from schizophrenia or drug addiction fell apart when they lost their access to their medicines. Often these patients have executive function issues and a setback can derail their recovery, the providers said.

The fallout can be dire in Washington, where patient advocates say barriers to drug-assisted treatment for opioid use disorder face a growing crisis especially among blacks, who accounted for more than eight out of 10 related last year to opioids dead, according to a report this month from the DC\’s office of the chief medical examiner.

DC has the second-highest opioid overdose death rate in the nation behind West Virginia, according to a CDC analysis of 2021 data, and many residents are struggling to access assisted medical care.

For opioid-dependent patients who rely on medication refills such as suboxone, a drug containing buprenorphine and naloxone used with counseling and behavioral health therapies to treat opioid use disorder, the cost of waiting can be a lifetime, said Beverlyn Settles-Reaves, care manager for the Urban Health Initiative at Howard University College of Medicine. Unlike a blood pressure medication, where a pharmacist can give a patient a few pills without disrupting the continuity of care, she said, these medications are tightly controlled.

She said a patient who was denied access to a pharmacy counter on a Friday afternoon told her he had resorted to buying the drug on the street, where he risked ending up with deadly fentanyl pills, because he feared experiencing withdrawal symptoms over the weekend, pending coverage approval.

That\’s the level of desperation they get to, Settles-Reaves said in a telephone interview after testifying. This is a life saving issue for them, their anxiety issues go off the charts when there is a crash with their medication.

I\’ve written about expensive drugs for years. So my baby needed it.

The process was once only used for new or very expensive drugs, but providers say insurance companies are increasingly looking to it in recent years. pre-approval for generics and commonly used drugs that were approved decades ago.

The most of [prior authorizations] I fill them in are actually for generic topical creams invented in the 1960s, Jack Resneck, a dermatologist and president of the American Medical Association, said during his testimony.

Yet the Kafkaesque nonsense of faxes and phone calls waiting hours for approval only to find that a denial has been mailed to a patient\’s home can go on for days and weeks, he said. Even using time-saving electronic portals can take days for results, the vendors said.

Nicole Du, a pediatrician at Children\’s National Hospital who testified on behalf of the DC chapter of the American Academy of Pediatrics, said when the liquid form of an antibiotic needed prior authorization she had to keep a 7-year-old patient overnight in addition to the hospital a greater expense than the drug that could have been sent to the patients\’ homes. Out of options, Du tried to teach her to swallow pills using a pack of Skittles from the vending machine.

Another time, Du said, she spent hours on the phone with a distraught mom who had to choose between paying $2,000 out of her own pocket or watching her 6-month-old suffer for days from a urinary tract infection.

Swartz, a doctor at MedStar Georgetown University Hospital who testified on behalf of the Washington Psychiatric Society, said his student patient finally got the right drug after convincing an insurance company doctor that it was necessary to avoid a heart arrhythmia caused from another commonly used drug.

It\’s a really big burden for our patients and for our medical colleagues, Swartz said in a telephone interview following the hearing. Delays can be really damaging to their momentum as people who are getting their lives back on track.

Some vendors have hired employees to handle the administrative burden of prior authorization; others have left the profession.

Carol Ann Dyer, a child and adolescent psychiatrist formerly in private practice in Washington, said she withdrew from direct patient care due to frustration and delays in care due to prior drug authorization requests.

I could no longer tolerate the sense of demoralization, the sense that my clinical care of my patients was being impeded, Dyer testified. And in light of the massive workforce shortage in child and adolescent psychiatry, it wasn\’t a decision I made easily.

Board member Christina Henderson (I-At Large), chair of the health committee, said she expected the board to act on the legislation, which could still be changed, later this year.

I can see how this can be demoralizing for doctors where you have another doctor who may not even be in the same field of specialty or training as you, who is now questioning your prescription for care, he said after the hearing.

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