I’m sure everyone can relate to being on hold for what seems like hours to get pre-authorization from an insurance company … First you have to choose from about 10 menu items, and within those menu items there are usually 3-4 more.
When, finally, a real voice comes on, you are flooded with relief. Now it’s time to ‘authenticate’ your account. Name, birthdate, account number, and answer to secret question, like perhaps your pet’s name. Then that real person says, “I’m sorry but you have the wrong department, please hold while I transfer you to someone who can help.” Then the same message comes on which gives you the same options, which none of them is the PA dept. You are once again on hold with music blaring in your ear, which is interrupted by a message similar to this: “we are sorry but hold times are longer than usual, please continue to hold.”
After a very long time, with that same announcement repeated dozens of times, another real person comes on the line and asks the same questions as before, and after you answer all the questions, you are finally authenticated once more, only to learn, you still are not speaking to the correct representative. You have wasted more than an hour and have gotten no further!
Now imagine if this is part of your job description, and you have to do this multiple times a day and some of the pre-authorizations you are seeking are for a chronically ill patient.
Dr. Daniel Soteres wrote the following case report to raise awareness about this condition plaguing the health care system. The condition is Prior Authorization Fatigue Syndrome (PAFS). This condition is the direct result of the circuitous process of prior authorization (PA). In addition to time wasted by physicians and their staff.
“I am the physician owner of a medium-sized allergy practice in Southern Colorado. In our clinic, we spend many hours navigating the PA system to obtain approval for a range of health conditions. PA for the medications often takes multiple hours over the course of several months to finalize. Meanwhile, there are ‘small PAs’ that we work on daily to make changes to preferred asthma inhalers, prescription nasal sprays, and other medications. ‘Small PAs’ take time too, but the goal of this letter is to outline how ‘big’ PAs drain the health care system and its workers.
I can sympathize with an insurance company that is trying to control costs for very expensive medications. However, the systems implemented appear to have the goal of delaying care for patients. The PA process delays access to medications, leading to increased illness, risk of exacerbations of underlying disease, ER visits, hospitalizations, and emotional stress for the patients and their caregivers. For health care providers, delays lead to frustration, emotional stress, increased risk of burnout, and additional work hours.
I have outlined a case to provide one example of the difficulties encountered while obtaining prior authorization. For this case, more than a dozen phone calls were made over two months. Each call takes at least 20 minutes, and several of the calls were 45 to 60 minutes long. Many offices are hiring additional staff to manage the time and effort required to get PA approval for medications. Most of the time, health care providers work on PAs in between patients during a busy clinic schedule or during lunch breaks and after hours at work or at home. This creates hours of unreimbursed work. The miscommunications, incorrect fax numbers, senseless ‘blanket’ denials, and other slights are more frustrating.“
Margaret is a 24-year-old female with asthma who came to the clinic for help with worsening asthma. Her problems started about a year ago during heavy pollution due to smoke from wildfires and her peak allergy season in the late summer/fall. She uses Nasonex and Claritin–D, and Xyzal for allergies. For asthma, Flovent 220 two puffs twice a day had worked well, but now she needed multiple albuterol treatments per day. In the past year, she required two treatments with systemic steroids. These steroid ‘bursts’ offered improvement, but her symptoms would steadily return over the following weeks. A few months before returning to my office she had an asthma attack that required two nights in the hospital and a prolonged oral steroid taper.
At her initial visit, we changed Margaret from Flovent to Advair 230, two puffs twice a day, and started Singulair. Returning to the clinic a month later, she reports some improvement.
However, she still uses albuterol a few times per week. We added Spiriva 1.25 mcg, two puffs once a day, and ordered labs to begin consideration for biologic therapy.
Her labs show an absolute eosinophil count = 100 and serum IgE = 93. She had a skin test 3 years ago that was positive for allergy to seasonal pollens and dust mites.
As the trials of add-on medications showed little improvement and the objective, laboratory data arrived, the need to consider other therapies became evident. This case is a slam-dunk among allergy/asthma specialists regarding the decision to trial biologic asthma therapy.
We started the PA process. It took two months and about a dozen phone calls to get her monoclonal antibody therapy approved. Sparing all the details of the call logs, I realized I was developing PAFS. I was asked to do a peer-to-peer authorization. I had a phone number and a case number. I sat down at my desk to eat lunch and made the call. More than 45 minutes, my call was forwarded four times to a different person. With each of these advancements, I was asked to spell my name, give my NPI number and phone number, and give the patient’s name and the case number. At the end of these calls, I was told that they had no record of a peer-to-peer call scheduled.
The barriers created by these processes are myriad:
- Inappropriate step-thru therapies
- Inappropriate timeline for urgent request
- Lack of communication from the insurance company
- Inaccurate confirmation numbers, fax numbers, or other points of contact
- Pharmacy intermediaries for the insurance company often create two or more confirmation numbers, faxes, or other points of contact.
PAFS is plaguing the American health care system. Many offices are hiring additional staff to manage the time and effort required to get PA approvals.
PAFS costs my practice and other health care systems hundreds of hours per year. The systematic implementation of measures to delay care for patients has a negative impact on patients’ quality of life, their families, and the health care providers.
Further analysis of the cost implications and psycho-social burden of PAFS is needed
This is just one example of a prior authorization process in our clinic. In my practice, I see patients who could benefit from some type of PA-associated drug at least once a week. Meanwhile, I have accumulated patients from 15 years of practice who require recurring PAs on a 6-12 month basis. All of these require similar processes and procedures.
The struggle is real for me and my staff. We have Prior Authorization Fatigue Syndrome (PAFS). I am calling on our medical societies and organizations, our third-party payers, and the pharmacy intermediaries to do something about it. This is a major barrier to improved health outcomes for many of our patients.”
Daniel F. Soteres is an allergist-immunologist.