Patients with chronic illness are often forced to jump through hoops to get drugs they need.
Opinion / Commentary – Wall Street Journal
By Craig Blinderman  Aug. 22, 2017 6:25 p.m. ET – Dr. Blinderman is an associate professor of medicine and the director of the Adult Palliative Care Service at Columbia University Medical Center.

One of the principal achievements of the Affordable Care Act was its prohibition on denying insurance coverage to patients with pre-existing conditions. Under the ACA, insurance companies must sell polices to people with chronic diseases and charge the same premiums paid by healthy people.
But patients with pre-existing conditions in fact are being denied coverage when their insurance plans don’t allow for medically recommended treatments or place significant obstacles in the way of getting them. Many plans impose “utilization management” rules restricting access to drugs by requiring prior authorization, quantity limits and so-called step therapy—making patients try a cheaper drug before taking a “step” up to a more expensive treatment.
While such restrictions generally don’t pose significant harms to patients whose conditions aren’t life-threatening, those with a serious illness like cancer or advanced dementia risk being denied treatments that are necessary for the relief of pain and other distressing symptoms.
Over the past 10 years caring for seriously ill patients, I have noticed a marked increase in demands for prior authorizations by insurance companies and other third-party payers before granting approval for certain medications, treatments or procedures. In 2006, according to a Kaiser Family Foundation study, 8% of brand-name medications covered under Medicare Part D required a prior authorization and 18% were subject to some form of utilization management. In 2013, those rates had jumped to 21% and 35%, respectively.
Utilization-management policies don’t actually reduce costs or improve patient outcomes. Time wasted by doctors and their staffs pursuing prior authorizations costs as much as $31 billion in lost productivity annually. A review of the literature suggests that any cost savings due to step therapy or formulary restrictions—only allowing the use of medications on a pre-determined list—are offset by resulting increases in emergency-room visits and hospitalizations. Researchers have found a negative correlation between formulary restrictions and health-care outcomes.
I have seen firsthand how patients suffer when recommended treatments for pain and other distressing symptoms are denied or delayed. One of my patients is a 64-year-old cancer survivor who developed a chronic pain syndrome following multiple surgeries. His insurance company required prior authorization and imposed a monthly quantity limit on the only safe, effective pain medication that he could take without side effects. The delay in getting the proper quantity of medicine led him to experience opioid withdrawal, increased pain, and loss of functioning.
Another patient was denied a prescription for a strong opioid after surgery on a fractured bone related to advanced cancer. I had deemed the medication necessary for her worsening pain. Her insurer rejected the request because she had previously filled a prescription and reached her monthly “quantity limit.”
While reducing health-care costs is essential, insurance-imposed cost-saving measures such as blanket requirements for prior authorizations do more harm than good. Perhaps a special exception should be carved out of the ACA for those with serious illnesses like cancer. Insurance plans, including Medicaid and Medicare, could enact a “preauthorized trial period” for all medications, dosages and quantities deemed necessary by a doctor for the management of severe pain or other debilitating symptoms. Following this trial period, physicians could be asked to justify continuation of the therapy.
Doing this would relieve patient suffering due to delays or disruptions in the amelioration of symptoms, reducing health-care costs in the process. More than half of all U.S. health-care spending goes toward care for the chronically ill and debilitated. Outpatient palliative-care programs reduce costs and unnecessary hospitalizations, improve symptom control and quality of life, and may even improve survival. When patients are denied coverage or experience significant treatment delays, these benefits are unlikely to be realized.
Medicine is about caring for the patient. Health insurance is about providing timely access to care. When health insurance limits treatments for seriously ill patients, it harms those who need care most.