Insurance rules keep patients from opioid, mental health drugs

Aug 21, 2023

In the two months it took for the insurance company to approve medication for D.C.-based psychiatrist Jacob Swartz's patient, he watched as the student's once-regulated attention-deficit/hyperactivity disorder and impulse control unraveled: A's and B's turned to failing grades, they were suspended and their self-esteem tanked.

While Swartz could see the toll of the delay, the fate of the child's well-being rested with someone who had never spoken with them — a growing trend faced by patients and doctors as insurance companies eager to cut expenses have sought more influence in treatment decisions.

Swartz was among several medical professionals who implored a D.C. Council committee this week to join lawmakers across the country who want to regulate the practice, known as prior authorization, which insurers use to determine if a medication or procedure is medically necessary before agreeing to cover some or all of it.

While insurance companies say a relatively small percentage of medication and services require approval, critics, including the American Medical Association (AMA), say prior authorization is overused, costs providers time and money, and delays treatment to patients with mental health and substance use disorders who are vulnerable to relapse when experiencing interruptions in care.

The bill before the D.C. Council, introduced by Brooke Pinto (D-Ward 2), would set deadlines for insurers to respond to prior authorization requests and appeals, allow denials only by a District-licensed physician with the same specialty as the patient's doctor, make approvals last at least a year and honor approvals for 60 days when a patient changes plans.

Reform bills were considered in 30 states this legislative session with at least a dozen still up for passage, according to the AMA.

The Biden administration last month revised prior authorization requirements for Medicare Advantage, a private insurance plan for seniors paid for with federal funds. A decision by UnitedHealthcare this year to require prior authorization for many colonoscopies brought national attention to the issue.

Kris Hathaway — vice president of state affairs at America's Health Insurance Plans, a trade association of health insurance companies — said Wednesday in testimony to the council's health committee that prior authorization, used in limited circumstances, helps lower patients’ out-of-pocket costs, prevents overuse of unnecessary or harmful care and ensures services are consistent with evidence-based practices.

She acknowledged the process can be burdensome and said companies are making an effort to target the practice to "high-tech imaging, elective services and specialty drugs."

Hathaway and insurance company executives were outnumbered by proponents of the measure who derided the practice's impact on care in testimony about patients whose fragile recovery from schizophrenia or drug addiction fell apart when they lost access to their medication. Often these patients have executive function trouble and a setback can derail their recovery, providers said.

The consequences can be dire in D.C., where patient advocates say barriers to medication-assisted treatment for opioid use disorder meet a ballooning crisis — especially among Black people, who last year accounted for more than 80 percent of opioid-related deaths, according to a report this month from the D.C. office of the chief medical examiner.

D.C. has the second-highest opioid overdose death rate in the nation behind West Virginia, according to analysis of 2021 data by the Centers for Disease Control and Prevention, and many residents struggle to access medically assisted treatment.

For opioid-addicted patients who rely on refills of medications such as suboxone, which contains buprenorphine and naloxone and is used with counseling and behavioral health therapies, the cost of waiting can be life-threatening, said Beverlyn Settles-Reaves, care manager for the Urban Health Initiative at Howard University College of Medicine. Unlike with a blood pressure drug, where a pharmacist can give a patient a few pills and not disrupt their continuity of care, she said, these medications are tightly controlled.

She said one patient denied access at the pharmacy counter on a Friday afternoon told her he resorted to buying the drug on the street, where he risked ending up with deadly fentanyl-laced pills, because he feared experiencing withdrawal symptoms over the weekend as he waited for coverage approval.

"That's the level of desperation that they get to," Settles-Reaves said in a phone interview after testifying. "This is a lifesaving issue for them; their anxiety issues go off the charts when there's a holdup with their medication."

I wrote about high-priced drugs for years. Then my toddler needed one.

The process was once used only for new or very expensive drugs, but providers said in recent years insurance companies have increasingly sought preapproval for generics and commonly used drugs that were approved decades ago.

"Most of the [prior authorizations] I fill out are actually for generic topical creams invented in the 1960s," Jack Resneck, a dermatologist and president of the American Medical Association, said during his testimony.

Yet the "Kafkaesque absurdity" of faxes and phone calls, with hours-long wait times to seek approvals only to find out a denial was sent through the mail to a patient's home, can go on for weeks, he said. Even using electronic portals intended to save time can take days for results, providers said.

Nicole Du, a pediatrician at Children's National Hospital who testified on behalf of the D.C. Chapter of the American Academy of Pediatrics, said when the liquid form of an antibiotic needed prior authorization, she had to keep a 7-year-old patient an extra night in the hospital — a greater expense than the drug that could have been sent to the patient's home. Out of options, Du tried to teach her to swallow pills using a pack of Skittles from the vending machine.

Another time, Du said, she spent hours on the phone with a distraught mom who had to choose between paying $2,000 out of pocket or watching her 6-month-old baby suffer for days with a urinary tract infection.

Swartz, a physician at MedStar Georgetown University Hospital who testified on behalf of the Washington Psychiatric Society, said his student patient finally got the right medication after he convinced a doctor with the insurance company that it was necessary to avoid a heart arrhythmia caused by a more commonly used drug.

"It really is a big burden on our patients and on our fellow physicians," Swartz said in a phone interview after the hearing. "The delays can be really damaging to their momentum as people who are getting their life back on track."

Some providers have hired employees to handle the administrative burden of prior authorization; others have left the profession.

Carol Ann Dyer, a child and adolescent psychiatrist formerly in private practice in D.C., said she retired from direct patient care because of the "frustration and the delay of care" due to prior authorization requests for medication.

"I could no longer tolerate the sense of demoralization, the sense that my clinical care of my patients was being interfered with," Dyer testified. "And in light of the huge workforce shortage in child and adolescent psychiatry, it was not a decision I came to easily."

Council member Christina Henderson (I-At Large), chair of the health committee, said she expects the council to act on the legislation, which may still be amended, before the end of the year.

"I can see how this can be demoralizing to physicians where you have another physician who may not even be in your same field of specialty or training, who is now questioning your prescription of care," she said after the hearing.