The Pulmonary Hypertension Association recently brought together insurance, pharmaceutical and specialty pharmacy companies to address treatment delays caused by prior authorization and re-authorization requirements.
The Payer Summit, which also featured health care professionals and a patient representative, is among the ways PHA is working to improve prior authorization. Earlier in the year, PHA formed a Prior Authorization Taskforce to develop a pilot program to streamline prior authorization. During the summit, attendees provided feedback on the proposed pilot program and discussed ideas for prior authorization improvements.
“Hearing from the insurance company that you can’t get the drug you need to stay alive feels horrifying especially when it’s for an administrative or bureaucratic reason,” Colleen Brunetti, 2020-2022 chair of PHA’s Board of Trustees, said in the payer summit. “It feels like someone is purposely denying you a life jacket in a storming ocean. It’s not personal on the company’s part, but it always feels personal to the patient who receives that denial.”
Brunetti explained how treatment disruptions take away from the limited time people with PH have left — time they can’t get back.
Tonya Zeiger, a respiratory therapist and PH coordinator at Mayo Clinic Jacksonville, also described how prior authorization delays affect patients. Prior authorizations frequently are becoming roadblocks to effective treatment, rather ensuring patient safety tool, she said. “They are causing delays that are making our patients less safe.”
Zeiger shared data from the American Medical Association and PHA about the burden prior authorizations put on health care providers. She urged stakeholders at the summit to work with PHA to save time and money and improve patient outcomes.
The proposed pilot program would improve lines of communication between accredited PH Care Centers and insurance payers. It also would eliminate or streamline repetitive prior authorization requirements.
Prior authorizations are insurance company practices that require prescribing physicians to submit documentation that patients meet established treatment guidelines before the insurance company agrees to cover treatment. Insurers use prior authorization to confirm that drugs are appropriate and cost-effective for treating a patient’s condition. After reviewing documentation and prior authorization requests, insurance companies can approve or deny prescriptions.
The practice creates problems for people with PH, especially when multiple rounds of denials and appeals are involved. Physicians sometimes must schedule meetings with medical directors from the insurance companies to discuss patients’ cases. The patients’ doctors must explain why the prescribed drug is the most appropriate treatment before the insurer approves a prior authorization request.
During the process, people with PH wait to receive life-saving drugs and sometimes must stay in the hospital for extra days or even weeks. Health care providers regularly devote several hours each week to prior authorizations, sometimes for medications with a six-month or less approval period. PHA believes this increasing administrative burden takes up valuable time that could instead be spent on direct patient care.
PHA will continue discussions about the pilot program and incorporate feedback from the summit into the final plan. In the next phase of the initiative, PHA will seek insurance companies willing to participate in the trial program.
Colleen Brunetti and Tonya Zeiger
