Advocating for Change: Enhancing Patient Rights in the Prior Authorization Procedure

Advocating for Change: Enhancing Patient Rights in the Prior Authorization Procedure

Physicians and patients have long been frustrated with the prior authorization (PA) process. The lengthy and frequently extremely complicated procedures that physicians must go through in order to have a treatment plan authorized cause delays in patient care. While the initial goals of PA, which were to control costs and guarantee optimal care, are commendable, the way the procedure currently operates frequently obstructs prompt treatment and shatters the patient-physician bond. We examine the existing PA process’s drawbacks in this blog post and suggest some improved patient rights that might result in a more patient-centric strategy.

The Current Conundrum of Prior Authorization

Despite the advancements in healthcare, the PA process has evolved at a different pace. It is often fraught with administrative burdens, with seemingly arbitrary denials leading to inevitable appeals. Physicians frequently report that the time and resources they dedicate to securing PAs detract from their ability to deliver care and can lead to burnout. On the other hand, patients often bear the brunt of delayed or unfulfilled treatment, which can significantly impact their health outcomes.

The critique of PA isn’t just anecdotal; it has concrete implications for the healthcare system. One study found that 40% of PAs are associated with a change in planned care and that one in five patients requiring PA did not receive the prescribed medication. This is a significant departure from the intended goal of PA, which was to prevent unnecessary treatments that could lead to overprescription and inflated healthcare costs.

Proposed Patient Rights in PA

It’s time to weigh the scale back toward what truly matters in healthcare – the patient. Here are several proposed patient rights that can help to address the shortcomings of the PA process:

Timely Access to and Treatments

Patients should immediately have a prior authorization decision. Studies indicate that these waits can lead to increased emergency department visits and hospitalizations, which not only disrupt the patient’s life but also add to the overall cost of healthcare.

Transparent Communication and Education

The PA process must become more transparent. Patients should be informed about it when a medication or treatment requires PA. This includes information about why the PA is necessary, what the approval process looks like, and what to expect regarding the timing of a decision.

Efficient and Streamlined Appeal Process

Patients should have access to a simple and efficient appeal process if a PA request is denied. This could involve clear guidance on how to appeal, the expected time for a decision on the appeal, and the option to speak with a healthcare provider or specialist during the appeals process.

Right to an Explanation of Denial

Patients have a right to understand why their PA request was denied. This right extends to a detailed reason that can be easily understood, including whether the denial was based on medical necessity, coverage under the patient’s insurance, or other factors.

Option for Consecutive Prescriptions

In cases where prior authorization is initially denied, patients should have the option to receive a limited supply of the prescribed medication or treatment to cover them until the process is completed. This consecutive PA process ensures that care is not delayed while making a decision.

Strict Guidelines for Non-Medical Switching

Insurers and PBMs should be prohibited from conducting “non-medical switches” of patients from one covered drug to another during a policy year or treatment plan. These switches, often made due to formulary changes, can disrupt a patient’s treatment plan and waste the resources already allocated to the initial PA process.