Prior Authorization Resources
You and your doctor have selected a new medication to treat your condition. You’re relieved. You’re hoping this treatment will perform better than the last. And you’re looking forward to improving your quality of life. But something stands between you and the drug your doctor prescribed. Before you can fill your prescription, or have it administered in the doctor’s office, you need your health plan’s approval. It’s a process known as prior authorization.
What began as a safeguard against unnecessary drug spending has become a significant barrier to patient access.
Cardiologist Seth Baum, MD, describes a hypothetical patient with a family history of extremely high cholesterol. “He’s not the typical cholesterol patient,” Dr. Baum explains, “And the typical medications, known as ‘statins,’ don’t lower his cholesterol enough.”
Patients can be denied access to their medicine for days, even weeks because of a practice called “prior authorization.” It’s the process whereby insurance companies must approve a physician-prescribed medicine, procedure or test before a patient can get coverage.
Respiratory illnesses are pervasive, chronic conditions that exist quietly in millions of Americans. Patients manage their breathing with varying degrees of success, since the ability to keep on top of symptoms depends heavily on a patient’s personal circumstances.
Paradoxically, respiratory health rarely gets the policy attention it deserves. The current health care paradigm is one of disease treatment, rather than disease prevention. Though prevention is the cornerstone of good respiratory health, the United States has fallen behind in addressing health care delivery for day-to-day treatment of chronic conditions.
Skin is an organ like no other. It can be seen and touched; it is instantly visible on ourselves and others. And in addition to dictating much of our outward appearance—which has vast social significance—our skin allows us our sense of touch and serves as armor protecting us from hostile environments and microbes.
Just as skin serves multiple functions, conditions impacting our skin can have a multifaceted impact. People who have skin conditions may experience feelings of isolation due to how the appearance of their skin is perceived. For patients with conditions like psoriasis or eczema that are connected to stress, these feelings can be doubly painful—isolation breeds stress, which in turn exacerbates the condition. Skin conditions can undermine a patient’s ability to function at work, school, home, or other social situations, meaning they can have a serious impact on a patient’s financial security and emotional stability.
The scope of cardiovascular disease’s cost, both financial and in human suffering, should not be underestimated. Heart disease costs the United States an estimated $30.7 billion per year. And the situation is only going to grow worse: The American Heart Association projects that 40.5 percent of the U.S. population will have some form of CVD by the year 2030.
The good news is that cardiovascular disease sits at the apex of priorities for the U.S. healthcare system. As a result, patients and physicians have access to a range of effective and time-tested treatments, such as statins, beta blockers and ACE inhibitors, as well as life-changing devices, such as pacemakers. Over the past few years, treatment options have expanded further to include significant new therapies that can help more patients gain better control over their symptoms, experience fewer side effects, and live longer lives with conditions like heart failure, high cholesterol and high blood pressure.
But obstacles threaten patients’ access to both new options and old, dissuading or outright preventing them from obtaining the best therapy or device. That’s because healthcare concerns are trumped by decisions based on short-term benefits. But by carefully advocating long-term solutions backed by experts—the physicians and providers on the front lines treating cardiovascular disease—we can radically improve the heart health of our nation.
An attitudinal survey of more than 350 heart disease patients, providers, caregivers and stakeholders revealed widespread concerns about how health plans delay access to life-saving medication. The issue affects a broad swath of the country. One-third of Americans have high LDL cholesterol, putting them at increased risk for heart disease, the leading cause of death in the United States. Meanwhile, one American has a heart attack every 40 seconds. For these people, unreasonable medication delays caused by prior authorization or step therapy can be serious, even life threatening.
Almost 1 in 10 Americans – men, women, and children of all ethnicities and income levels – has diabetes. One of the most common medical conditions in America, diabetes has become more widespread in recent years, increasing by more 1 million people between 2012 and 2015 alone.
Not surprisingly, diabetes is an expensive disease. In 2017 diabetes cost the United States $237 billion in direct medical costs and $90 billion in reduced productivity, accounting for about one in every four health care dollars spent. People with diabetes incurred an average per-patient cost of $16,750 a year.
Diabetes’ impact and prevalence demand policies that allow people to access appropriate medications and effective health care.