Prior Authorizations — primary care’s bane of existence

I received an email from a staff member who was covering me while I was at a conference last week. A patient of mine who has been on a stable dose for 3+ years for restless legs syndrome with great clinical response was trying to refill his medication and was told that his plan only covers 3 months out of the year now. He needed me to fill out a prior authorization in order to get his medication covered.


A Prior Authorization (PA) is a requirement that a physician obtain approval from the patient’s health insurance plan to prescribe a specific medication for the patient. PA is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.

The burden that PAs place on primary care is well known in medical groups, but I’m not sure how much patients or other stakeholders in the healthcare system know about it. The AAFP has been fighting this for years. In primary care every hour of patient encounters generates 2 hours of administrative tasks, to which PAs certainly contribute.

PAs contribute to the phenomenon every hour of patient encounter time generates 2 hours of administrative tasks.

Instead of banging my head against the wall like I usually do in this situation, I decided this time to document the time spent for each step. I grabbed the phone and called the number provided. I listened to the phone tree and after about 2 minutes got to a human being. She asked for the patient’s insurance number, which I didn’t have. I supplied her with the case #. We spent about 5 minutes clarifying what medication, dose, quantity, ICD 10 code — which I had to look up on the fly — then she placed me on a brief hold.

Ten minutes later, she was asking what other medications had been tried — since she had been on this medicaiton for 3+ years, I couldn’t remember off the top of my head the other 5–6 medications she had tried, specific dosages, and how long she tried each one.

She transferred me to the pharmacist after about 5 minutes, and he also asked me some clarifying questions, told me about the timeline about when to expect a decision. To their credit, they offer an expedited request vs regular request. I chose the regular request since it wasn’t a medication that needed to be filled in the next day or two. Out of curiosity, I asked the pharmacist how much this medication would cost without insurance. His response? $16.50 per month. In other words I was on the phone so that an insurance company can save $150 for one year (to cover the other 9 months). I spent about 30 minutes on the phone in total, with about 5–10 minutes of that time being placed on hold, another 5–10 minutes discussion patient demographics, etc, and 10 mins of discussion of the medication at hand and actual decision making happening. I could have spent those 30 minutes seeing 2 patients who had a same day/urgent need.

In other words I was on the phone so that an insurance company can save $150.

Some people will point out that what I did was completely unneccessary — I could have used a service such as CoverMyMeds to save some time and have a better paper trail. I figured that since the case number had already been opened, it would be faster since the request was already in the system. I couldn’t find an easy way to integrate that case number into the patient’s file. Others might point out that in a lot of functioning systems medical assistants or nurses can help with these requests to help everyone work towards to top of their license. This is a valid point, but my main critique is that it still means that someone has to do it, and the system as a whole is not taking into account that there is waste going into the healthcare system. By having a medical assistant do that same work we do reduce waste but we do not eliminate it completely.

Now, I am not saying that we do not need checks and balances for healthcare spending. About one in every three dollars spent on healthcare goes to waste. I would argue that by having a physician (or nurse or medical assistant) make that phone call adds to waste in the system that could be spent on active patient care. I also believe that insurers shouldn’t have to cover any prescription written by a provider. If there is a high value (high efficacy and low cost) first line agent that is the standard of care — such as metformin for diabetes — then we be encouraging that vs paying for the latest-expensive-flashy diabetes med that the pharmaceutical industry has been advertising directly to consumers.

What we need is prior authorization reform, particularly in the public system, and to financially punish bad behavior. At most, a prior authorization should take 5 minutes and should be a standard, electronic form that can be prepopulated with the patient/provider information, integrating into whatever electronic health record is being used. Since we are all about measuring quality and measuring things these days in healthcare, we should start measuring how much time prior authorizations are taking and impose a performance penalty to insurance companies that take more than 5 minutes to get information from a provider. Add a double penalty for every minute that a provider/nurse/medical assistant is on hold on the phone.

While it sounds harsh, the more I am convinced that these types of penalties are necessary to force cooperative behavior from all parties who don’t have an incentive otherwise to do the right thing.

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