There are two words that strike terror in pediatricians caring for children with a chronic or complex disease— “prior authorization (PA)”. This often leads to much time and effort to get approval for a treatment that payers want to restrict because of its high cost. Besides the burden on a provider and office staff to process a PA request, what about the burden on patients? Can the delay for treatment be led to increased healthcare utilization for a patient?
Constant et al (10.1542/peds.2021-052501) studied the role of prior authorization for standard-of-care biologic medications for inflammatory bowel disease (IBD). Among 190 patients under 18 years of age with IBD seen at one children’s hospital, 141 required PA. The median time to initiation of a treatment regimen from the time it was recommended with PA required was 25 days versus 13 days if it was not needed. PA was granted for all patients that needed it. Interestingly, there were increased emergency department visits and hospitalizations over the next 180 days for those that required PA and had to wait for it. Those who required PA were also more likely to receive ongoing systemic corticosteroids. Although it is not possible to demonstrate that PA led to these outcomes, it does suggest that more needs to be done to streamline the PA process.
The authors of this study make a plea to modify the PA process now that we have evidence-based care guidelines for things like biologics or even to turn to legislation if payers still will not grant approval for therapies without the hassle of a PA. We solicited a commentary from Dr. Stacey Cook, Ms. Anna Desmarais, and Dr. Jay Berry, from the Complex Care Service at Boston Children’s Hospital, who note their personal experience caring for the patients requiring PA, the complications following the waiting for approval, and suggest using quality-improvement methods and better collaborations among clinicians, payers, and patients and families to improve the PA process (10.1542/peds.2021-054843). If we cannot do away with the need for PA, we can at least make it better for all the stakeholders involved and reduce the potential problems associated with it for patients and practices. Read this study and commentary—and I suspect you will be of the same mindset as the authors of both articles that when it comes to PA—we can all contribute to making it better!