IfPA’s Health Policy Blog explores health policy news, reports, initiatives and events through the lens of a single question: What is the impact on patient access?

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The Reauthorization Tragedy

By Salima L. Brillman, MD

Maybe it’s loss of balance and involuntary movement, or speech difficulties and cognitive impairment. My patients with neurological conditions often experience similar symptoms.  Yet each patient is unique.  

That’s why, a few years ago, I left a workplace committed to one-size-fits-all care pathways, and I set out to focus on patient-centered care.  Now I go to patients’ homes and their workplaces.  Other times they come to my office, or we visit via video.  

This flexibility is just one way that I am able to meet the unique needs of each patient.  Being able to choose the right medication for each patient is another. That capability, however, is often difficult because of insurance barriers.

Treating people with Parkinson’s disease provides a good example.  While there remains no cure, the treatment toolbox has rapidly expanded in a short period with the release of nine new medications in just the last six years.  This should be a boon for patients – and their doctors.  Too often, though, insurers tie our hands.

Typically, providers like me must fight for our patients’ right to take one of these new medications, working through a process called prior authorization.  It’s a red-tape nightmare, which makes gaining approval feel so good.  From there, treatment should be smooth sailing.  But that’s hardly ever the case. 

In a matter of months, insurers require “reauthorization.”  They want me to prove the patient still needs the same medication he or she’s been taking for the past few months.  It’s a pointless exercise, especially for those living with progressive, chronic conditions.  Both their condition and their need for medication to manage it will never go away. 

I’ve seen the back and forth of reauthorization take so long that patients run out of medication, having to default to a less effective option or go completely without.  This stresses patients and their caretakers.  Due to the increased stress, it’s common for patients’ motor symptoms, such as tremor, as well as non-motor symptoms like anxiety, to re-emerge. 

It’s frustrating, too, because patients don’t just bounce back after the insurer grants reauthorization and patients are back on their regular medication.  It can take months or longer to get back to baseline, to regain the same level of function they had.  In the meantime, patients are exposed to more risk.  For example, those with balance issues are more prone to falls and hospitalizations. 

If the idea of repeating this process a couple times is daunting, imagine doing it for the rest of your life.  For people with Parkinson’s disease, that could be 20 or 30 years.  Losses caused by waiting for medication over and over again can affect their independence and quality of life for decades to come.

In comparison, people living with Huntington’s disease usually have a much shorter life expectancy, often between 10 to 20 years from diagnosis, and few treatments are available.  The debilitating condition can cause movement, speaking and breathing challenges.  Patients’ cognitive issues such as memory lapses, difficultly concentrating and psychiatric problems will worsen with time.  It’s really appalling to delay treatment for people trying to cope with such a serious condition.   

Yet providers like me will still have to request insurer reauthorization.

The situation is tragic.  Every patient deserves access to the medication that will give him or her the best outcome.  By treating patients like just another expense on the balance sheet, however, reauthorization robs them of health, independence and precious time.

Salima L. Brillman, MD, is a movement disorders specialist in California and a member of the Alliance for Patient Access.

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