Prior Authorizationed to Death

A free public service for a better community

Nov 01, 2023

Welcome to November, Advocates

I would like to encourage you to send comments and suggestions. If there is a special topic you’d like to see please let me know. Please use the comment button below. It is now.

Affordable Care Act - Start Shopping

November 1st is the beginning of enrollment for those who purchase health insurance on their own via the Affordable Care marketplace. Last year about 16.3 million did so. Millions who were dis-enrolled from Medicaid, so-called unwinding when the COVID-19 pandemic was declared over, will also be shopping for plans.

Here is the federal site, healthcare.gov, for the 32 states that use it. Or use this link for the 18 states and the District of Columbia that use their own.

Changing insurers might mean a lower premium. Online calculators, including one at healthcare.gov, can provide subsidy estimates.

The entire report published by NPR is here. Of course, if we had Universal Healthcare we wouldn’t have to do any of this. I’m just saying.

Prior Authorization (PA) Hell

Recently we did a story on claims denials and prior authorization denials. Insurance companies claim they are making sure that treatments are covered by the insurance plan and are suitable. The most charitable thing I can say is that they are second guessing the doctor. The effect of their behavior is that they are holding on to funds and keeping them invested as long as possible so that those funds continue to earn profits for them. Insurance companies are allowed to use “clinical data” to deny claims or treatment. They are not required to disclose the source of the data and it frequently causes discomfort, distrust and death.

Simple XRAY or MRI Example

Let’s start with a fairly trivial example. I tore the meniscus in my knee. My orthopedist examined it and said he needed an image to see the tear so he could repair it. He told me to go get an X-ray. I questioned him because an X-ray would not show the soft tissue tear. He let me know that my “Cadillac” insurance demands an X-ray first because it is cheaper than the MRI I really needed. Once the Xray shows nothing then w will do the MRI, then we will schedule surgery. This delay took about 3 weeks. If I could have had the MRI the doctor wanted, I could have been mending the same week I saw him. Somewhere that insurance company’s clinical data said it was overall cheaper to do X-rays first and hope to find the problem, than actually do what my doctor knew was right. Hold that thought.

Tragic Consequences

Here is a Youtube link to several stories about the evils of prior authorization. In one a physician describes how she requested a wheel chair for a patient who had no legs. The request was denied because the doctor did not describe how having no legs would inhibit mobility.

Another story was about someone who had cancer and needed an MRI to confirm. By the time her MRI was finally approved 5 weeks had elapsed and her particularly aggressive cancer had spread so far that her leg had to be amputated.

JAMA Study on Prior Authorization

Now comes a study reported in the Journal of the American Medial Association a few days ago on the effect of prior authorizations (PA) on cancer patients. Here is a link to the study.

This cross-sectional study of 178 patients with cancer with experience with PA showed delays to care (with most delays ≥2 weeks), increased anxiety, and patient administrative burden. The PA process was rated bad or horrible by most respondents and was associated with decreased trust in the health care system.

This study suggests that PA for cancer care can have discrete negative associations with outcomes for patients; streamlining the process is key to optimizing the quality of care delivered and improving the patient experience with cancer care.

123/178 (69%) patients experienced a PA delay in care. 90 of those delays were for more than 2 weeks. 119/178 had to be personally involved trying to resolve the issue with the insurance company. 35 of them spent 11 or more hours being involved. 148/178 trust the health care system far less.

Worst is that 22% of the patients never received the care for their cancer!!!

Delayed to Death

I know we present many statistical reviews of the healthcare situation in the US and sometimes it is hard to comprehend the tragedy that those numbers represent.

A friend of mine here in Washington described a tragic situation. In Port Townsend a dear friend of hers lost her husband recently to cancer. They had health insurance with a commercial company. He needed to be admitted to the hospital. Instead of covering admittance to the hospital, his commercial Medicare Advantage plan covered only observation, resulting in getting more than $10,000 in bills, and screwing over Jefferson Healthcare, which also didn't get fully reimbursed for the excellent care they provided. Repeat this episode at least once a month for the last six months of his life, and you'll get a minor look at the hell her poor friend went through. She lost nearly half her savings paying for things their insurance was supposed to cover but wouldn't. And she's so grief-stricken she has no fight left in her.

ACTION

I recommend sharing any and all of these stories with your member of Congress and Senators. It is easy to pass the buck on healthcare when democracy is in the balance, but people are dying and this is something they can fix. You can find their contact info in the Resources section below. The RESISTBOT Text Below is a sample script.

Use RESISTBOT by texting SIGN POVJZV to 50409 to send the email below.

“I am your constituent and I want to bring to your attention the abominable state of insurance companies delaying and denying claims and denying treatment with prior authorizations. People die from these delays and no one is held accountable.

Here are some examples for you: A Journal of the American Medical Association study found that of 178 cancer patients 22% never received needed treatment because their insurance companies DENIED TREATMENT. Here is a link to the study for you. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810824?resultClick=24

Here is an article, this week, from NBC on how Medicare Advantage is declining to pay for medically necessary treatments in order to increase profits and how this damages rural healthcare - https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012#

I just learned of a woman in Port Townsend, Washington whose cancer stricken husband was denied medically ordered hospital admittance for treatment. The insurance company refused to pay and his wife was left with $10,000 in bills. This happened once a month for 6 months. He died and she lost half her life savings.

Now is the time to get on the right side of healthcare. For the sake of all of us, please stop siding with profit-minded insurance companies. I recall all the GOP claims that Obamacare would lead to death-panels and rationing; now that role is being fully played by insurance companies who are standing between people and their healthcare. Because rural or urban, we all want to see a doctor at a local hospital. We all want our local hospital to be open. No one, rural or urban, wants some corporate insurance giant located in another state telling them they don't need this test or that procedure.

We need a complete overhaul of our healthcare delivery systems. Widows who watched their spouses die should not also watch their bank account be depleted for corporate profits.

I believe Universal Healthcare, like HR 3421, public insurance paying private providers is a step in the right direction. If you have a better idea bring it forward, because the greed in the system is killing us. Please stand on the right side of history on this one.

I need to know what you plan to do, I expect a response from you.”

RESOURCES

Healthcare Advocacy (Us)

Website

Our Newsletter resources including reproductive healthcare

Healthcare Advocacy Reading List

Find My Elected Officials

Contact the White House https://www.whitehouse.gov/contact/

Contact State and Federal Representatives

By phone: (202) 224-3121
By email: democracy.io

Important Healthcare Resources

League of Women Voters Healthcare Reform Toolkit

Organizations to Contact

National Nurses United Medicare4All

Physicians for a National Health Program

One Payer States

Healthcare Now

Reproductive Health

NARAL - Pro Choice America

Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion

Planned Parenthood

Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.

United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.

Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.