Research Confirms Prior Authorization Burden for Heart Patients

February 7, 2018

Insurance red tape is wearing down doctors who prescribe advanced cardiovascular drugs – and that could be bad for patients.

New research from the University of Pennsylvania details prior authorization requirements for PCSK9 inhibitors.  The self-injected drugs lower bad cholesterol for patients with cardiovascular disease or genetic high cholesterol.  Prior authorization allows health insurers to act as a gatekeeper, deciding whether they will cover the medication when it’s prescribed by a patient’s health care provider.

University of Pennsylvania Findings

Calling the health plan requirements “so high that they raise real concerns about access barriers,” University of Pennsylvania researchers found that:

  • 82-97 percent of health plans require prior authorization for PCSK9 inhibitors.
  • Many plans ask doctors to submit patients’ actual medical records rather than simply answering questions on a form.
  • Many plans asked doctors to provide documentation on patient histories. That’s problematic for patients who have changed doctors over time.
  • Plans often required patients with inherited high cholesterol to prove their diagnosis through genetic testing. Such testing is not standard and typically not covered by insurance.

Different health plans have different forms and requirements, increasing doctors’ administrative burden.  The additional paperwork introduces more opportunities for error, researchers noted.  Health plans can use those errors to justify coverage rejections.

Health Plan Rejections

Rejection rates were the topic of a 2017 report card series from the Institute for Patient Access.  Data showed that health plans refused to cover prescribed PCSK9 inhibitors for more than one-third of patients nationally.

So what do burdensome paperwork and rampant health plan rejections mean for patients?

The requirements “could take time away from patient care,” explained researcher Jalpa Doshi, PhD, adding, “It raises the question of whether patients seen by physicians with greater administrative capacity, rather than those with the greatest medical need, are more likely to receive approval.”

The University of Pennsylvania’s research analyzed prior authorization policies covering more than 275 million Americans and spanning 3,872 plans.  Coverage included commercial, health insurance exchange, Medicare and Medicaid populations.

For more on how health plan barriers impact patients, see the Partnership to Advance Cardiovascular Health’s video, “Access Barriers Affect Real People.”

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