Insurer prior-authorization delays put lives at risk

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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.

Considering these challenges, I stand with M Health Fairview, the Minnesota Hospital Association and the Minnesota Medical Association in calling for legislative reforms targeting the appropriate use of prior authorization. Critical services, including cancer treatments aligned with national oncological guidelines, medications for substance use disorder treatment, generic drugs deemed therapeutically equivalent by the FDA, preventive treatments, pediatric hospice services and neonatal abstinence programs, should not be subject to unnecessary bureaucratic hurdles.

Private and public insurers must be held accountable for the disparities they perpetuate and the risks they impose on vulnerable patients when they overuse prior authorization processes.

Minnesota is leading the way in pioneering new therapies and treatments, but we fall behind other states in reimbursements for those innovations. We can’t have it both ways; we cannot simultaneously be a leader in breakthrough health care and lag in equitable compensation. Essential reforms are needed to cultivate a health care system that prioritizes patient well-being and ensures equitable access to timely and vital care. It is time for systemic changes that prioritize the health and well-being of our most vulnerable population.

Dr. Lucie Turcotte is a pediatric hematologist-oncologist at M Health Fairview Masonic Children’s Hospital and an associate professor of pediatric hematology/oncology at the University of Minnesota Medical School, where she is also co-director of the pediatric leukemia/lymphoma program and director of pediatric cancer survivorship research. Prior authorization is among subjects scheduled to come before the Minnesota Senate Health and Human Services Committee on Wednesday.