Madelaine Feldman, MD, FACR
Vice President of Advocacy & Government Affairs, CSRO
Posted: September 18, 2024
As a rheumatologist, I am dedicated to improving the lives of patients suffering from chronic autoimmune diseases like rheumatoid arthritis, lupus, and psoriatic arthritis. These conditions, often crippling, necessitate prompt and productive treatments to manage symptoms and avert irreversible joint damage and other long-term complications of uncontrolled inflammation. However, an increasingly significant barrier hinders my ability to provide optimal care: the onerous process of prior authorizations.
Prior authorization, the requirement for physicians to obtain approval from health insurance companies before prescribing certain medications or treatments, was initially designed to control costs and ensure the appropriate use of treatments. However, these policies have spiraled into a bureaucratic nightmare, creating unnecessary delays, negatively affecting patient outcomes, and increasing costs.
Every day, my staff and I spend countless hours on paperwork and phone calls, navigating the convoluted approval processes that differ across different health plans. This time-consuming task detracts from the time I could spend with patients. More importantly, it significantly delays the initiation of vital treatments for my patients.
Patients with autoimmune diseases do not have the luxury of waiting. These conditions are progressive, and delays in treatment can lead to severe and often irreversible damage. Imagine telling a patient experiencing excruciating pain and inflammation that they must wait days, or even weeks, before receiving relief because their health plan has yet to authorize the prescribed medication. The frustration and helplessness they feel are palpable, and as their physician, I share in their distress.
Studies have shown that prior authorizations can lead to worse health outcomes. A 2022 survey by the American Medical Association (AMA) found that 94% of physicians reported that prior authorizations have delayed patient care, and 33% said these delays have led to serious adverse events such as hospitalization, disability, or even death. In a 2022 survey by the Alliance of Specialty Medicine, 92% of specialists reported that prior authorizations hurt patient clinical outcomes. In my specialty, a recent study out of Mass General concluded that prior authorizations for IV medication use in rheumatology patients are associated with delays and denials of treatment, leading to greater use of steroids—a very bad outcome for patients—even in those patients who were ultimately approved. Because the majority were eventually approved, the study questions the value of PAs and states that a re-evaluation of their negative impact on patient safety is needed.
This issue is particularly pronounced in the context of Medicare Advantage (MA) plans, which have been implementing increasingly restrictive prior authorization requirements. Reports by the Office of Inspector General (OIG) have noted significant flaws in the prior authorization processes used by MA plans, indicating that many prior authorization denials are inappropriate, with some being overturned at rates as high as 75% upon appeal. This data underscores the flawed nature of initial decision-making and the undue burden placed on patients and providers. And, for our senior patients, who often have more complex health needs, these delays can be especially detrimental and ultimately increase the cost of care. Prior authorizations are no longer just a hindrance—they constitute a healthcare crisis.
In response to broad concerns about prior authorizations, the Centers for Medicare & Medicaid Services (CMS) has made efforts to address these insurer practices through rulemaking. Recent policy changes aim to streamline the prior authorization process and reduce the administrative burden on healthcare providers, but they fall short in one critical area: medications. CMS specifically excluded medications – both medical and pharmacy. As medications are the cornerstone of treatment for autoimmune diseases, these new policies offer no help to our patients, and delays in access to care and treatment continue.
Because of this need for greater reform, the Coalition of State Rheumatology Organizations (CSRO), along with its coalition partner, the Alliance of Specialty Medicine, supports the Improving Seniors’ Timely Access to Care Act (S. 4532/H.R. 8702)) – a bipartisan bill that aims to streamline the prior authorization process within Medicare Advantage by establishing an electronic prior authorization system, creating transparency standards, and ensuring timely responses to prior authorization requests. When it comes to medication access, the legislation takes a step in the right direction. Although it unfortunately excludes medications covered by Part D from applicability, it contains no such exclusion for medications covered by Part B. Since drugs administered in-office are covered by Part B, this legislation will be a crucial step towards reducing delays and improving health outcomes for our senior patients who rely on these complex medications.
I urge policymakers to recognize the detrimental impact of prior authorizations and to seek reforms that streamline the process. By supporting legislation like the Improving Seniors’ Timely Access to Care Act and addressing the critical issue of medication approvals, we can ensure that patients receive timely, appropriate care and improve their overall health outcomes. It is time to put patients first and allow physicians to do what they are trained to do: provide the best possible care without unnecessary impediments.
Madelaine Feldman has been in private practice for over 25 years and is based in Metairie, LA. She is the current Vice President for Advocacy and Government Affairs for the Coalition of State Rheumatology Organizations (CSRO).
