The health strategist
the most comprehensive knowledge center,
for fixing and digitizing health care
Joaquim Cardoso MSc.
Servant Leader, Chief Research & Strategy Officer (CRSO),
Editor in Chief and Senior Advisor
January 23, 2024
Article published by KFF Health News on January 18, 2024.
What are the key points?
Patient Frustration with Prior Authorization:
Paula Chestnut, a smoker at high risk for lung cancer, faced delays in obtaining an MRI due to prior authorization hurdles, impacting her treatment options.
Prior authorization is highlighted as a major source of frustration for both patients and doctors within the American healthcare system.
Critical Delays in Cancer Treatment Approvals:
Cancer patients, whose timely treatment is crucial, experience challenging delays in the approval process by health insurers.
A 2023 study reveals major insurers issuing “unnecessary” initial denials, particularly in cases related to endocrine and gastrointestinal cancers.
Limitations of Biden’s Crackdown on Prior Authorization:
While a new rule by the Biden administration addresses prior authorization issues, it has limitations.
The rule only impacts insurers involved in specific federal programs, excluding the majority of Americans covered through job-based insurance.
Online Activism Against Prior Authorization Denials:
Doctors and patients resort to online platforms, such as Twitter, to share instances of prior authorization denials and highlight the human impact.
Eunice Stallman, a psychiatrist, shares her experience of her 9-month-old daughter being denied authorization for a crucial brain tumor medication.
Affordability Challenges Despite Good Insurance:
Sally Nix, despite having good insurance, faces hurdles in securing approval for expensive monthly infusions needed to manage her pain disorders.
Nix’s case exemplifies that even individuals with comprehensive insurance coverage are not guaranteed affordable care.
Impact on Patients’ Lives:
Sally Nix’s experience with intravenous immunoglobulin infusions illustrates the tangible impact of insurance coverage decisions on patients’ daily lives and well-being.
Patients like Nix express frustration and navigate a complex process of prior authorization, affecting their access to necessary treatments.
Call to Share Personal Stories:
The article encourages readers to share their own prior authorization stories as part of the “Deadly Denials” series, highlighting the widespread impact and challenges faced by individuals dealing with this system.
As a smoker for 40 years, Paula Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease. But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KFF Health News.
Though Roux doesn’t fully blame her health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”
Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years. Read more here.
Cancer Patients Face Frightening Delays in Treatment Approvals
Delaying cancer treatment can be deadly — which makes the roadblock-riddled process that health insurers use to approve or deny care particularly daunting for oncology patients. A 2023 study found that major insurers issued “unnecessary” initial denials in response to imaging requests, most often in endocrine and gastrointestinal cancer cases.
Biden Cracks Down on Prior Authorization — But There Are Limits
While the new rule is a good start, it goes only so far. It affects only insurers doing business in certain federal programs. Notably, though, the CMS rule doesn’t impact prior authorization demands by insurance that some 158 million Americans get through their jobs – the most common kind of coverage in the U.S.
Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials
In July, Eunice Stallman, a psychiatrist based in Idaho, joined X, formerly known as Twitter, for the first time to share how her 9-month-old daughter, Zoey, had been denied prior authorization for a $225 pill she needed to take twice a day to shrink a large brain tumor. “This should not be how it’s done,” Stallman said.
Woman Petitions Health Insurer After Company Approves — Then Rejects — Her Infusions
Even people with good insurance aren’t guaranteed affordable care. For more than a decade, Sally Nix, of Statesville, North Carolina, has suffered from autoimmune diseases, chronic pain, and fatigue, as well as a condition called trigeminal neuralgia, which is marked by bouts of electric shock-like pain that’s so intense it’s commonly known as the “suicide disease.”
Late in 2022, Nix started receiving intravenous immunoglobulin infusions to treat her diseases. The infusions allowed her to start walking two miles a day with her service dog. But a few months after starting them, she found out her insurance company wouldn’t cover their cost anymore.
To read the original publication, click here.
