The Prior Authorization

The Prior Authorization

Another day at the office, that I am a physician in a small town. It is Monday morning and I am running late. My nurse herds me quickly towards my first patient.


The patient is a 42 year old man with a history of Diabetes. He lost his job as a construction worker 3 years ago and consequently lost his insurance. He recently got a new job and regained insurance and has come to see me. He has completely neglected his Diabetes in those years. He is married and a devoted father to two young children.


My nurse comes to me to tell me that his hemoglobin A1C is 9.6%. This is a test that we do in the office that gives us an average of his sugars over the last 3 months. Normal is 6.5% or less.


I have several medications available to me. Each on average can reduce his hemoglobinA1C by 1%. Appropriate diet can add another 1%. Thus for a 3% drop, I will need two medications and an appropriate diet.


One medication is the generic Metformin which is usually the first medication tried on Diabetics. There are also several newer medications that get at the root cause of Diabetes, but these are not generic. They are available in combination with the Metformin (which is included at no additional cost). At random I pick one that will be one pill once a day. I give him all this information on Diabetes and the proper diet to follow and send him on his way.


An hour later, my nurse tells me that the pharmacy has called and this drug requires a ‘prior authorization’. A ‘prior authorization’ is used by insurance companies to keep costs in control, by trying to restrict some of the newer and more expensive drugs. Now the nurse has to get on the phone with the insurance company to try to get this approved. 


It takes 45 minutes to get someone on the phone. Usually it is someone with no medical training, who follows the insurance company’s standard algorithm. ‘Has he had a trial of Metformin alone for at least a month’ they ask? No, the doctor feels that he will need more than just Metformin answers the nurse. They said that they will send their decision in two days. We get a letter the next day that the request has been denied and he needs a trial of generic Metformin alone first.


Many thoughts come to my mind. How is it that an insurance company is legally able to alter a physician’s medical decision? Interestingly if the patient has a poor outcome, it is almost impossible to legally sue the insurance company.


So I put my patient on Metformin alone, knowing that it probably will not be sufficient.  My nurse wasted 45 minutes yesterday, and will waste another 45 minutes next month. The insurance company will save on the cost of the medication for about a month.  One study assessed that prior authorizations cost US doctors approximately $ 31 billion a year.


I wish there was a better way!