Insurance companies often restrict University of Utah Health physicians from prescribing the optimal drug for a patient's illness.
Providers are left to choose between the second or third choice after insurers initially deny coverage, in part, to steer doctors and patients toward lower-cost options. In some cases, patients have to go through months of ineffective treatment to merit a more expensive drug, said Erin Fox, senior pharmacy director at University of Utah Health, which has an entire pharmacy technician team devoted to prior authorizations.
"Our providers are overall especially frustrated with prior authorizations because they often aren't allowed to prescribe what would be the best treatment for an individual patient," she said, noting the "step therapy" or "fail first" requirement. "The patient has to pay copayments for these visits and may suffer overall worsening of disease state while they make the case to the payer."
Prior authorization can delay care, since those decisions typically only happen during normal business hours, Fox noted. When physicians want to start a medicine while a patient is still in the hospital, University of Utah Health's inpatient pharmacy team must determine whether the treatment will be covered in the outpatient setting. That means patients may end up staying in the hospital over a weekend without receiving the appropriate treatment, Fox said.
Prior authorization is part of a myriad of administrative roadblocks bogging down the healthcare system. Insurers, drug manufacturers, physicians and patients spend at least $93.3 billion a year on navigating that administrative complexity, most of which is borne by patients and their physicians, researchers from Novartis Pharmaceutical Corp. and the University of California, Berkeley estimated in a new study published in Health Affairs on Monday.
Patients spend approximately $35.8 billion a year in drug cost sharing after accounting for copay support. Physicians devote $26.7 billion in time to navigate utilization management, and manufacturers invest $24.8 billion in drug donations, discounted copays and administrative support. Payers spend around $6 billion administering prior authorizations, the "conservative" analysis of peer-reviewed papers, industry reports and articles found.