The Hidden Costs of Prior Authorization, with Colin Banas, MD

According to the 2023 AMA Prior Authorization Physician Survey, 33% of doctors report that issues with the prior authorization (PA) process (PA) have resulted in serious adverse events for their patients and 88% describe the burden associated with PA as high or extremely high.

In an interview with The Educated Patient, Colin Banas, MD, MHA, chief medical officer of DrFirst, explains the PA process and the challenges patients face when waiting for PA approval, particularly for those with rare and chronic diseases.

The PA process is a system implemented by payers to ensure that expensive specialty medications are prescribed appropriately. However, the process is often tedious, time-consuming and lacks transparency. Providers frequently don't know if prior authorization is required until days after sending the prescription, leaving patients in the dark. The lack of clarity leads to delays, confusion and potential gaps in treatment, as patients often find out at the pharmacy that their medication hasn't been approved yet.

Banas says this disjointed system creates friction in patient care and can delay necessary treatments for conditions like cancer or severe autoimmune disorders. As a doctor and patient, he knows firsthand how frustrating this process is, even for those well-versed in the system. One of the most concerning consequences is that patients or providers may abandon the process due to its complexity, leading to untreated conditions.

Moreover, patients who have been on a medication for years might have to re-qualify for it if their insurance changes, adding yet another obstacle. The system is also marred by a lack of price transparency, leaving patients unsure about their out-of-pocket costs.

These barriers not only cause delays in care but also potentially worsen health outcomes. Banas explains that sometimes does not know that a patient never received their prescribed treatment until a follow-up months later due to these issues. Ultimately, he believes must be a more efficient way to manage this process to ensure timely and appropriate care for patients.