Pediatricians, even those delivering emergency care, are not immune to the woes that prior authorization creates for patients and the physicians caring for them.
On any given day across the nation, pediatric emergency physicians may see parents bringing in a child who is having a medical crisis while they await prior authorization for a medication that had been successfully treating the condition the child is now being seen for.
Physicians might be forced to figure out how they can administer a medication to a 2-year-old when the insurance company will only approve the needed drug in pill form.
Meanwhile, a parent may seek emergency care as they try to work around the prior authorization system that denied or delayed needed care.
“One of the things I see quite often is a failure of the prior authorization process and families bringing their children into the emergency department, begging us to provide the care that their kids need in a timely manner,” pediatric emergency physician Melissa J. Garretson, MD, said during the an episode of “AMA Update” focusing on how prior authorization slows care for kids.
“That's a failure all the way around,” said Dr. Garretson, a member of the AMA Board of Trustees. “The cost of emergency care is much higher than planned, deliberate care when you have the ability to wait for that to happen. But the fact that delays take six weeks, three months, six months as you fight through the prior authorization process is totally unacceptable.”
The latest AMA survey of 1,000 physicians (PDF) about prior authorization puts some hard numbers to those delays and costs, including:
- Nearly 90% of physicians reported that prior authorization leads to higher overall utilization of health care resources, with nearly half saying that happens “often” or “always.”
- 94% reported that prior authorization led to delays to patients’ access to necessary care.
- 78% reported that the process can at least sometimes lead to patients abandoning their physicians’ recommended course of treatment.
- 24% reported that prior authorization led to a serious adverse event for a patient in their care.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Prior auth hurts kids’ well-being
When it comes to prior authorization, insurers don’t seem to factor in the fact that kids aren’t just little adults, said Dr. Garretson, who practices at Cook Children’s Health Care System in Fort Worth, Texas.
“Kids aren’t just going to lay there for a painful procedure. Kids can’t swallow medications that are in tablet form—a lot of times even 14-year-olds,” she said. “There’s a lot more flexibility that’s required taking care of pediatric patients and insurance companies have a one-size-fits-all and that doesn’t work, especially in terms of prior authorization.”
Take for instance shortages the past couple of years for attention deficit disorder medication. Often an insurer only covers one type of the different formulations of the various medications available to treat the disorder—anything else requires prior authorization.
“Imagine, as a pediatrician with a child who's doing well in school on their particular ADHD medicine and now you can't find it. And then you can't get the new one prior approved because it's not the one that's covered — even though there's a nationwide shortage. It makes no sense to me,” Dr. Garretson said. “As a pediatrician, my goal is to help kids stay healthy. …When you make it impossible for me to do that, that truly is a moral insult to, in my soul, what I want to do as a physician.”
What you can do
Dr. Garretson urged physicians to reach out to their state and federal lawmakers to encourage them to pass laws that would put a stop to some of the insurance companies’ tactics.
After some progress on the state legislative and federal regulatory fronts last year, Congress is poised to take action to make more improvements to prior authorization this year.
In June, bipartisan groups in the House and Senate introduced legislation that would streamline and standardize how Medicare Advantage uses prior authorization. The AMA supports the legislation, the Improving Seniors’ Timely Access to Care Act of 2024.
Meanwhile, numerous state legislatures are considering bills that would address prior authorization concerns at the state level.
“None of us signed up to be physicians who couldn't provide the care that we know our patients need at the right time and the right place. And that is incredibly frustrating,” Dr. Garretson said. “We all need to get involved in this and fight this problem.”
“AMA Update” is your source for physician-focused news. Hear from physicians and other experts on trending public health concerns, practice issues and more—because who’s doing the talking matters. Catch every episode by subscribing to the AMA’s YouTube channel or listen to all AMA podcasts at ama-assn.org/podcasts.
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