What can we do to rein in the tactics insurance companies use to deny policyholders life-saving drug treatments?
Obamacare required insurance companies to offer all enrollees 10 essential healthcare benefits.
Not surprisingly, prescription drugs were one of them. Nearly 60 percent of American adults use prescription treatments for everything from depression to cancer. Yet, it has become harder and harder for patients to access the drugs their doctors prescribe as prior authorization becomes an increasingly-used requirement for insurers to cover prescribed treatments.
Doctors have become almost inconsequential in treatment decisions, which is demoralizing for doctors and dangerous for patients. Neither Obamacare nor recent repeal efforts addressed this dangerous and increasingly prevalent problem.
Even when a doctor has chosen a treatment based on sound medical science, that prescription can be vetoed by insurers if we do not obtain prior authorization for certain drugs. A drug may be listed on the insurer’s approved formulary, but requires the insurer’s permission before it can be dispensed. That is telling. It means the insurer does not have a legitimate clinical concern about the treatment, but is only worried about its cost.
When prior authorization requirements second-guess doctors and delay patient treatment, they put insurance company profits ahead of patient care.
Prior authorization also does not reduce total healthcare costs; it merely shifts many of them to doctors. Added together, the average doctor spends three full weeks out of every year dealing with unnecessary insurance company requirements like prior authorization. That is time diverted from seeing patients and diagnosing illnesses. It is also time that is not compensated.
Often it is simply wasted time, since insurers end up granting close to 80 percent of authorization requests, eventually. Prior authorization requirements usually just delay treatment in the hopes that the doctor will cave and substitute the insurer’s preferred drug. But even when doctors prevail, it does not feel like a victory.
Defending our treatment choices to insurers who may never have completed a day of medical school is demoralizing, especially as most insurance company authorization rules do not even give a doctor the benefit of the doubt on the basis of the dozens of previous successful justifications.
Insurers are also aggressively turning to another method for denying vital drug treatments: formulary exclusions, or the lists of drugs they explicitly will not cover. Over the past five years, CVS Caremark, the nation’s second-largest pharmacy network, quadrupled the number of drugs it excludes, from 38 exclusions in 2012 to 168 today.
For the first time, CVS has even excluded cancer treatments from its formulary. It will no longer cover Gleevec or Tasigna, two drugs from Novartis used to treat chronic myeloid leukemia. CVS also axed Xtandi, a Medivation Inc. drug for treating prostate cancer. If the company’s past is any indication, expect the number of cancer drugs it excludes to rapidly expand over time.
When insurance companies exclude drugs or refuse to pay for prescribed treatments until patients—and doctors—have conquered all the obstacles they erect, insurers are effectively blocking access to one of the most essential healthcare benefits.
Congress should tell insurers that the price of the perks they are getting with the latest healthcare overhaul is a commitment to honor doctors’ recommended prescriptions and refraining from using prior authorization or formulary exclusions to deny patients the drug treatments essential to their health.