Denied: The Harsh Reality of Prior Authorization

Imagine how you would feel if you were a patient treating an illness with a doctor-recommended prescription, and your insurance company decided to effectively override his decision. Insurance companies have weaseled their way into a position to have the final say in medications patients receive—through a process known as prior authorization. This puts people who are more interested in investor health than your health, and that is exactly what my fellow patients and I have had to face. What may have begun as a legitimate effort to curb fraud and abuse, is now weaponized to find any penny possible and keep patients from obtaining necessary medications. That’s a burden that they shouldn’t have to take on: a scheme whereby a benefit goes underused or unused, leaving patients frustrated or worse, but pads “big insurance’s” P&L numbers for Wall Street’s benefit.

While I am relieved that this issue is getting some attention (as seen in this opinion piece), too little is being done about this back door rip-off that puts insurance bureaucrats between you and your doctor.

I have experienced this first hand, these unhelpful doses of friction and anxiety. While results may vary, the aim is clear: patients will just give up trying to get what they’re entitled to.

As someone living with Multiple Sclerosis, my physical symptoms take multiple forms, including physical fatigue and muscle weakness.

Early in my diagnosis, fatigue was a major issue for me. Then, my neurologist prescribed a treatment used by B-2 pilots to fight fatigue when they needed to fly from US bases halfway around the world and back again without stopping. The generic version of this drug was called modafinil, and when I used it, it was a great relief. Working full-time and coming home to relieve my saintly wife who was home with our four boys, at that time all under seven years old, it was a miracle.

My doctor and I were pleased with the result. When I would take it before days of extraordinary challenges, it gave me a tailwind to push through my life without harming my health. It wasn’t a cure, but it was helpful assistance with managing some of the symptoms I had then.

Much to my surprise, when my refills expired and my local pharmacy obtained the new prescription, the insurance company would tell my pharmacist not to fill it until the doctor would justify it. Again. Alright, a double-check seemed warranted. I could see this as reasonable because the medication wasn’t designed or approved for exactly my case. But then this occurred every time I needed more refills. I would be forced to have the awkward denial interaction with the pharmacy and contact my doctor to fight for my medication – again – so we could treat my condition. All while my medication was held hostage.

This harassment was frustrating and ultimately led me to find an alternative. After all, the medication was not absolutely necessary for me to stay alive. But it did help me to live.

If I needed to judge the Scouts’ pinewood derby race or go take my son to hockey practice at oh-dark-thirty, I would need to self-prescribe something more than coffee. So I decided it wasn’t worth the headache and harassment to me or my doctor, and chose to get a subscription to a steady supply of 5-hour energy shots. It is a simple workaround, but with hindsight, it strikes me as the plan all along: hit patients with so much grief that they “choose” to give up. I was able to pay out of pocket for an over-the-counter, quasi-medical solution and “save” big insurance from paying for legitimate claims with their passive-aggressive shakedown.

Although this medication didn’t cure my MS, it offered a break from some debilitating side effects that were increasingly burdening my body that a neurologist wanted me to take.

So, instead of having access to the proper medication to treat my symptoms, I was forced to “juice” courtesy of Amazon, not under medical supervision or even suggested by a physician. I am fortunate that I had the option to find another “treatment” for a non-life-threatening condition. Sadly, other patients are not so lucky.

During the last decade, my MS has progressed, and the doctors and I see a more vital role for modafinil. The fatigue is more pronounced and taking this medicine daily allows my vocal cords and muscles of my palette to make sounds that are understandable. Without the power I get from the dose of 200mg daily, my ability to communicate verbally is a hot mess. The difference now is the necessity of having drugs drives me to take on the bureaucratic obstacles. So, I’ll make the scores of phone calls and put my doctor through the bean counter Q&A.

 Of course, insurance company friction remains as grinding as ever. Worse, in fact. Their flex in patients' faces to save the cost of a few pills now means my 30-day supply is exactly that, a 30-day supply. Just-in-time delivery may be an effective way to run a large business to manage inventory of summer slacks or winter tires, but not for patients. If I can’t get my prescription because of bad weather or a bad MS day, good luck to my kids’ teachers who call, because I might as well have a mouth full of marbles.

To workaround the added stress of cutting it so close, I break some of my pills in half and take 150 mg daily instead of the 200mg I’m prescribed. It’s not a major difference and is done mostly to appease my anxiety until I build up a small surplus of tablets. It’s not life or death, but it’s a choice I shouldn’t have to make because it’s a system that cares less about patients than nickels and dimes.  

In fact, I am only one of millions of patients who have become victims of prior authorization.

The bottom line is that treatment should be between you and your doctor, and while insurance companies and big hospitals play a necessary role in our healthcare system, their vision is blurred by dollar signs.

My case is nowhere near the worst example. Regulatory delays or even restrictions to treatment brought on by prior authorization have cost patients their lives. Prior authorization too often puts patients who are reliant on their doctor-prescribed medications in an even more vulnerable position. The value of a human life should take precedence over an insurance executive's bonus. We need to carefully look at tools like prior authorization that are used to mindlessly deny patients access to lifesaving treatments. Enough is enough.