Opinion editor’s note: Star Tribune Opinion publishes a mix of national and local commentaries online and in print each day. To contribute, click here.
In January of last year, a young patient and her family sat in my office confronting the heartbreaking news of her cancer diagnosis. Urgent treatment was crucial, given the potential airway compromise associated with Hodgkins lymphoma. Transitioning from shock to determination in a matter of hours, we settled on a treatment plan of chemotherapy based on extremely favorable results from a recent large international study.
However, a significant hurdle emerged. Despite the urgent nature of the case, the patient’s high-risk medical status and the medical efficacy of our treatment plan, the patient’s insurance provider insisted on a prolonged prior authorization process. We were forced to reconsider treatment plans, threatening the patient’s well-being and placing an unnecessary financial burden on the family.
As a pediatric oncologist at M Health Fairview, I am gravely concerned about the prior-authorization requirements and the detrimental impact they are having on the timely and equitable treatment of patients in our state. Conveying a cancer diagnosis to a teenager is inherently challenging. Telling them their treatment hinges on approval from their insurance provider, which can take weeks, is gut-wrenching and infuriating.
Unfortunately, this case is not an anomaly. While private and public insurers claim prior authorization is used for cost and quality control, the process has become widespread across the health system, particularly for services that are essential, preventive or time-sensitive, leading to care delays, patient abandonment, and, in some cases, serious adverse events. Sadly, one-third of physicians surveyed by the American Medical Association recently reported that prior authorization has led to a serious adverse event for a patient in their care.
In the case of the 15-year-old with Hodgkins lymphoma, our care teams and system administration explored multiple treatment avenues, spent countless hours and made dozens of phone calls to the insurance company, and finally sent a letter to the state attorney general. Suddenly, after little to no response, the insurer approved the patient’s treatment, 25 days after she had been diagnosed. The prior-authorization process failed this patient by subjecting her to delays in care that could have been catastrophic to her health.
National data show that physicians, on average, complete 41 prior authorizations per week and spend more than 13 hours weekly obtaining approval, often for routine care. Data from my health system indicate that 75% of prior authorizations are approved on the first pass. Of the remainder, 75% are approved upon appeal. If nearly 95% of prior authorizations are ultimately approved, the net is being cast too wide. And who pays the price? Patients.
I take my role as a physician and leader within our pediatric leukemia and lymphoma program very seriously. I have a responsibility to each patient and family that I see to provide them with the best opportunity for long-term cure and minimization of chronic health consequences, regardless of their insurance or socioeconomic status.
