Battling Prior Authorization Over the Holidays
It’s the day before Thanksgiving and instead of catching up on grading and writing, I’m on the phone with physicians and my health insurer.
The feeling is exasperating, albeit not unfamiliar, having not only written a book on health insurance coverage denials, but having done so out of personal experience with such challenges.
This time, the problem is my antidepressant. I have not made a secret out of the fact that I struggle with often severe major depressive disorder as well as generalized anxiety disorder and post-traumatic stress disorder from multiple sexual assaults during my graduate school training. For many years, I have been able to manage it well with medication and therapy, though the particular cocktail of medications took years and multiple doctors to fine-tune in order to head off major depressive episodes and the accompanying SI that has stolen years from me. Ketamine treatment has saved my life and I have the privilege of supportive family that has helped me to manage the cost, as it is typically not covered by insurance due to being deemed experimental despite its years of proven effectiveness in addressing treatment-resistant depression. But in between rounds of ketamine, for the last 4.5 years, I have relied on the generic antidepressant desvenlafaxine (a.k.a. Pristiq), an SNRI with more manageable side effects than its related drugs.
Due to experiencing a challenging few months, my doctor determined that an increase from 100mg to 200mg was appropriate.
The problem: Despite being the same generic drug I’ve taken since June 2019, it required a new prior authorization.
After receiving a text message from CVS informing me that they needed to contact my physician for authorization of the medication, I informed my physician, who learned of the prior authorization trouble. When it was not resolved, he called my pharmacy benefit manager and felt confident that it would be resolved after he spoke with a live agent. But when I tried to fill the prescription, I learned that the prior authorization was denied. And what’s more, I was out of medication.
My physician prescribed an alternate SNRI while trying to appeal the denial, though the alternative drug (Effexor) has a considerably worse side effect profile, which exacerbated my increasingly prominent depressive symptoms which improved though were not resolved by a booster series of ketamine injections. And while my physician tried to pursue the peer-to-peer review of my case, he struggled to find the time between appointments given the lengthy amount of billable time spent on hold in hopes of resolution. All of this trouble for a generic, Tier 1 drug without a cheaper alternative.
The likely end has come into view: staying at the lower medication dose that had proven ineffective for my symptom severity.
I am, unfortunately, not in the minority in this respect – far from it. The American Medical Association’s survey of physicians finds that 94% reported that prior authorization induced delays in care while waiting for the necessary authorization, and 80% observed that prior authorization can lead to treatment abandonment. Additional research has found that prior authorization leads to 37% of prescriptions being abandoned by discouraged patients. The irony, of course, is that this prescription abandonment can have the effect of driving up costs if patients experience symptom exacerbation in need of more costly intervention.
Those who appeal health insurance denials have decent odds of winning, even though few are aware of this fact: I find in my nationwide survey of 1,340 U.S. adults that the majority of people expect that people win appeals 20% of the time or less, and that 52% of those who did appeal were actually successful in doing so (though predictably, those who estimate lower odds of success are disinclined to appeal their own denials, so there are informational barriers in need of rectifying). Thus, care is not finally denied so much as it is rationed through accumulations of inconveniences.
In their seminal work on administrative burdens’ impediments of access to program benefits, Pamela Herd and Donald Moynihan evaluate the learning, psychological, and compliance costs associated with navigating administrative burdens. It is not difficult to observe these costs in the context of challenging adverse health insurer determinations regarding needed care.
One must know there is a prior authorization requirement to change the dose of an existing medication. One must expend substantial time and effort necessary to navigate the labyrinthian American health insurance system – from communicating the insurance challenge to the physician to spending hours during the business day being rerouted on the phone among insurance staff to communicate the necessity of the prescribed drug at the appropriate dose. And one must do so while feeling unwell physically and/or emotionally, with these administrative burdens thus taking a substantial psychological toll on patients.
And if I’m experiencing these three dimensions of burden and their demoralizing effects, I know that the less privileged and less health literate are.
The problems I am facing do not reflect a bug in the system. They are without a doubt a feature.
I am in hands of good physicians, some in-network and some not, and I work hard to ensure that I can make the investment necessary to be productive in the work I love and to be the best spouse and friend and daughter I can be. There will be a solution, even if I don’t see it now. But is this true for other patients? It is, unfortunately, unlikely.