The Psychological Warfare of Prior Authorization


Shikha Jain, MD, FACP, felt the urgency of the moment.

It was 10:00 AM. A young patient had stepped into her Chicago cancer clinic. His face was red, and he was struggling to breathe.

The man had primary mediastinal B-cell lymphoma, a rare, aggressive form of non-Hodgkin lymphoma. Many cases involve large, fast‐growing masses that expand into the lungs and compress respiratory pathways, sometimes leaving patients breathless.

Jain rushed to his side and walked him from the clinic to an ICU bed at the hospital nearby.

“He was so sick,” recalled Jain, currently a tenured associate professor of medicine in the Division of Hematology and Oncology at the University of Illinois Cancer Center. “He needed chemotherapy immediately.”

The standard chemotherapy regimen at the time — R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) — required prior authorization.

Jain’s patient did not have days to wait, so Jain requested an expedited approval. The insurance company responded quickly, denying the request for treatment.

That evening, after hours on the phone trying to reverse the denial, Jain was able to arrange a peer-to-peer conversation with the insurer. She explained her patient’s pressing need for chemotherapy: he would die if he continued to wait.

But Jain’s argument did not move the reviewer. At that point, she had reached her limit.

“I asked for gentleman’s full name. I told him he would be responsible for this 30-year-old man’s death, and my next call would be to CNN,” Jain told Medscape. “And that is how I got my patient’s chemotherapy approved.”

Her patient received the regimen that evening. He later went into remission.

This incident occurred almost a decade ago, but it has stayed with Jain. She knows that her persistence in that moment meant the difference between her patient’s life and death.

Since then, Jain has confronted a growing onslaught of prior authorization requirements. Her days are often sidelined by prior authorization paperwork and calls.

There was the denial for standard-of-care staging and surveillance imaging — dotatate PET/CT — for her patient with neuroendocrine cancer. “The specific insurance company simply doesn’t approve this imaging, despite being around for years,” she said.

There was the patient with metastatic colon cancer who needed third-line therapy. His insurer took more than a month to reverse its denial for a recently approved drug, and in that time, the man’s disease progressed. “He eventually succumbed to the cancer after receiving the drug, but it’s unclear if his life was cut short by the delay in care,” Jain said.

And there is the maze of insurance company phone calls and transfers. On one call, Jain recalled being transferred six times before being connected to the right department to discuss approving standard-of-care chemotherapy for a patient. After being denied approval, Jain was put on hold to speak with a manager, and the call was abruptly disconnected.

“I have wasted so many hours on prior authorization and have seen months and months of patient care delays,” Jain said. “It’s easy to see why people just give up.”

For Jain, prior authorization has begun to “feel like psychological warfare,” she said. “To have everything questioned by people who don’t understand the basics of oncology is demoralizing.”

The growing administrative ― and emotional ― burden of prior authorization is contributing to physician burnout.

According to Medscape’s ‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023, more than half of oncologists reported feeling burned out this year — the highest percentage in 5 years. When asked what factors led to burnout, most doctors surveyed pointed to an overabundance of bureaucratic tasks, and specifically, “insurance companies telling me how to practice medicine and controlling what the patients can and can’t do.”

“Burnout is a real problem in medicine,” said Kelly Anderson, PhD, MPP, assistant professor in the Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora. “While there are many factors that contribute to burnout, prior authorization is certainly one.”

In a 2022 survey from the American Medical Association (AMA), 88% of respondents reported that the burden associated with prior authorization requirements was “high or extremely high.”

Although insurers argue that prior authorization cuts down on unnecessary and expensive care, physicians in the AMA survey reported that this practice often leads to greater overall use of healthcare resources, including more emergency department and office visits.

“Insurers are confident that prior authorization is saving money overall, but there’s also no clear evidence of that,” Anderson noted. “Prior authorization may reduce spending without harming patients in some instances, but in others, it’s adding administrative burden, costs, and may be causing harm to patients.”

This is part of our Gatekeepers of Care series on issues oncologists and people with cancer face navigating health insurance company requirements. Read more about the series here.

Please email [email protected] to share experiences with prior authorization or other challenges providing or receiving care.

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