Without insurance assistance, many patients are unable to afford CGMs, which contain parts that are short-lived and must be continuously repurchased. Photo by Simple Health Plans from Flickr Creative Commons.
Dealing with a chronic condition such as diabetes is a difficult thing, affecting daily life from the moment of diagnosis. While not an easy task, management of diabetes is possible with the right medications and supplies. However, an insurance requirement known as “prior authorization” (PA) presents a significant obstacle to obtaining the necessary tools for the treatment of diabetes.
A continuous glucose monitor (CGM) is one such tool, reporting wearers’ blood sugar levels to their smartphones every five minutes. These relatively new instruments are a vast improvement to the traditional finger-prick method. Instead of drawing blood onto a test strip around four to ten times a day, diabetics can get nearly-constant readings and receive warnings when their blood sugar becomes too high or low. Because blood sugar concentration can change drastically throughout the day, it is critical for diabetics to be aware of and thus better able to regulate their blood glucose levels.
Without insurance assistance, many patients are unable to afford CGMs, which contain parts that are short-lived and must be continuously repurchased. Under certain insurance policies, PA further limits access to these devices. Every time patients need to purchase new parts for their CGMs, their doctors must reaffirm to the insurance companies that the patients truly need the monitors. When problems or delays in PA arise, patients can be left without functioning monitors. Inadequate management of diabetes can lead to serious health complications and even death, so insurance companies should not make treatment even more difficult than it has to be.
Diabetics are not the only patients negatively affected by PA, which requires physicians to receive approval from a patient’s insurance company before prescribing certain treatments. If a doctor does not acquire PA, the patient has to pay for the costs of the treatment out-of-pocket. For patients who have high medical costs, especially due to chronic conditions such as diabetes that require ongoing treatment, this becomes a real issue.
In an ideal world, every patient would have full access to healthcare, regardless of cost. Unfortunately, the world is not ideal, and insurance companies have to ration their funds to ensure that they can supply expensive medications to patients when essential. The goal of PA is to ensure that resources and services are not being wasted if they are not medically necessary for a patient. However, the current PA system places undue burden on physicians and can result in real harm to patients. Hence, the PA system must be amended to suit the needs of the cornerstone of the entire healthcare system: The patients.
On average, PA requests consume two business days per week of physician and staff time, leading to overwork and less time available to spend with patients. If a PA is denied and a patient cannot cover the cost of treatment, physicians are unable to provide their patients with the proper care. Therefore, it should come as no surprise that 86% of surveyed physicians report PA to be a significant problem in their practice.
Long wait times between filing a PA request and receiving a decision delay patient access to treatment. This delay has detrimental effects on patient care, as patients are left without whatever service they need. Unclear distinctions for which treatments require PA also increase this waiting period. Furthermore, the difficulties associated with PA have led many patients to give up on their treatments altogether, and 28% of physicians report that PA has caused a serious adverse event defined as “death, hospitalization, disability/permanent bodily damage, or other life-threatening event” for their patients.
The purpose of health insurance is to increase access to healthcare and prevent exhorbitant associated costs. However, current insurance policies such as prior authorization impede this mission. Patients with diabetes should not need to send repeated requests to their insurance companies via their physicians to continue accessing a life-saving device. A more streamlined prior authorization system should be implemented that reduces processing times, clearly states what treatments it applies to, and gives more power to physicians to decide what constitutes a medical necessity for their patients.
Veronica Eskander is a contributor for The Daily Campus. He can be reached via email at veronica.eskander@uconn.edu.
