Patient Health Hangs in the Balance when Doctors are on Hold

This is a chilling scenario; far, far from the Halloween ‘BOO!’ kind of scary we think of this time of year. Gynecologic cancer surgeon, Dr. Barbara Goff, describes the nightmare that patients, caregivers and physicians experience when seeking treatment for complex diseases. Dr. Goff alarmingly declares that “patients die” while doctors are on hold with insurance plans, waiting to convince a reviewer at the insurance company to pay for treatment.

When the first and second therapy options fail for a patient, physicians lean heavily on their medical expertise and years of training; then they look to the horizon of medicine. In some cases, highly specialized combinations of drugs or those showing overwhelming promise in clinical trials represent the only remaining treatment option for some patients. Insurance plans often balk at coverage of these treatment options because the treatment is considered experimental or lacks enough published studies in which the drug was used to treat other patient’s with the same rare, complex condition. When treatment is denied, a patient’s physician embarks on lengthy, bureaucratic, opaque appeals process. Doctor after doctor describe navigating a process that begins with seeking pre-authorization for treatment from a reviewer that lacks expertise in the patient’s disease state or familiarity with the body system it impacts. Is the best outcome really possible when ophthalmologists review ovarian cancer treatment appeals? Dr. Goff rightly states that insurance plans “do need to authorize use of expensive drugs to ensure that patients are receiving appropriate treatments.” However, when pre-authorization processes are deliberately difficult and driven by cost containment goals rather than concern for patients, priorities are dangerously off-track.

Legislation has been introduced that would streamline prior authorization so doctors can do what they have been trained to do, care for patients. The Improving Seniors’ Access to Timely Care Act, H.R. 3107, has been endorsed by over 370 patient and medical provider organizations. Putting a middleman, with inadequate clinical experience in the medical decision making chain undoubtedly disrupts the personalized treatment plans that physicians carefully develop for each patient, restricts real-time decision making by doctors and hasn’t been shown to generate any cost savings for patients. Patients and Providers United amplifies the voices that seek to keep patients and providers at the center of medical decision making by telling policymakers Don’t Complicate My Care!