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Imagine you wake up and your vision is blurry. Your doctor will refer you to a specialist, but your insurance will prevent that referral. Please call me to defend why you think this patient needs this. That causes blindness. Imagine you have multiple sclerosis. Without warning, your insurance will stop administering your medication. No, we cannot give you this medicine. So it becomes paralyzing. Imagine your father has cancer. His doctor ordered an MRI on him. No, you cannot instruct this image capture. Prescribe chemotherapy. Have you considered other, cheaper options?His insurance is causing delay after delay. No, this surgery is not necessary. he dies An absurd process has permeated American medicine. This is called pre-approval. Here’s how it works: Insurance requires that doctors prove necessity before treating you. This is often a time-consuming process and can cause dangerous delays. sorry. Your cancer can be cured, but you will have to wait until your insurance company approves chemotherapy. That’s Dr. Jain. She is barricaded every day with prior permission. This is a really big issue and it affects everyone in this country who has insurance. Pre-approval was actually created to save costs. Decades ago, they were used sparingly and only when expensive treatment was absolutely necessary, such as long-term hospitalization. But now we’ve evolved into a system where things are rejected, often for no real reason. Even everyday medications now require insurance approval. Possible medicine to treat heartburn. ADHD medication. Test strips that allow patients to check their blood sugar levels. chemical treatment. Prozac. 95% of the time you will need to get permission before prescribing any medication. The New York Times Opinion interviewed more than 50 doctors and patients. Their experience shows that insurance companies often weaponize this common process to control doctors and increase profits. If the insurance company denies treatment or delays treatment, the money should be kept by the insurance company. The way they profit is by denying care. As prior authorization became widespread, delays in treatment became the norm. There are also tragedies. One in three doctors say the disease has caused serious medical problems or killed one of their patients. Ocean went blind. I felt like the insurance company told me, “My life doesn’t matter.” For four months, Michael could not walk or stand. Like, I’m scared of MS, but right now my fear is more of the insurance company. And Vivian lost his father. He couldn’t spend time with his father because he ended up spending so much time on the phone, writing letters, and faxing. This is medical fraud disguised as paperwork. If your prior approval is denied, you have three options. All you have to do is pay out of pocket. However, this is not realistic as medical costs are prohibitively high. It’s okay to give up. This happens up to 80% of the time and is advantageous for insurance companies. Alternatively, your doctor can go to bat for you. If the previous authorization was denied, you will have to perform a so-called peer-to-peer. Peer-to-peer is supposed to be a phone call where you call someone who is your peer to justify the treatment you want to provide. I’m a pediatrician, but in some cases I’ll talk to a neurologist. People who couldn’t pronounce the name of the drug I was trying to prescribe. In many cases, it’s not even the doctor. Imagine that he has to do it 5 to 10 times a day. What’s even more ridiculous about this whole process is that after going through all of this, if you’re a really determined healthcare provider, you’ll probably be able to get a drug or procedure approved. Insurers say this process helps “reduce high treatment costs,” “ensure safety” and “reduce total treatment costs.” But what it actually does is create a lot of costly bureaucracy. The company has four full-time employees who are dedicated to obtaining pre-approval for treatments for Crohn’s disease and ulcerative colitis. And that applies to him only in one disease state. By some estimates, the United States spends approximately $35 billion annually on preauthorization administrative costs. These resources can be dedicated to patient care and responding to calls in a timely manner. You might actually be able to go home and see your family on a regular basis. In a confession of sorts, some companies are actually promising to reduce prior approvals. But these efforts only scratch the surface. I am a board-certified gastroenterologist. I know what I’m doing, but it’s just blocked by all of this bureaucracy, red tape that actually only serves to enrich the insurance companies. Cigna earned $5.2 billion last year. Elevance earned $6 billion. United Healthcare made $22 billion. There was a patient who was newly diagnosed with lymphoma. And the insurance company gave us a hard time getting chemotherapy. Someone called me. And I said to that person: “I need your name, because if this young man dies, I want to tell his parents who caused it.” After returning home and hanging up the phone, I felt too emotionally exhausted. I cried. And that was just one patient. I was seeing 25 other patients that day. And many of them will eventually require prior permission as well. Prior authorization gives insurance companies more power than doctors. Now, there are some complex cases where it makes sense to double check whether the doctor is overprescribing unnecessarily. Imagine you have a cancerous tumor removed. To be on the safe side, doctors recommend additional treatment, which will cost $170,000. On the other hand, I can understand where insurance companies would want to carefully consider these expensive treatments. On the other hand, I am a human being and a young mother. What is the value of my life? Sarah’s insurance denied treatment. The question is, do you think they made that decision based on her best interests or theirs? In many countries, these tough ethical decisions about coverage is done by the government, not by commercial insurance companies. The government should abolish or at least reform prior approval. My goal with Senate Bill 247 is to reform the pre-commitment process. House Bill 3459 creates a streamlined pre-approval process known, quote, as “gold carding.” Several states have created gold card programs. Physicians who have obtained prior authorization in the past do not need to obtain authorization again. All states and the federal government should pass such laws. Insurance should not be a barrier between you and the medical care you need. After 12 weeks, I was finally cleared to see a neuro-ophthalmologist. And he said, “We’re going to do this surgery, but it’s just to preserve what vision you have left. If we had seen it sooner, things would have been different.” Then maybe you can see it now. Maybe I could have had a different life.
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