When a patient is struggling with gastrointestinal (GI) health issues, such as rectal bleeding, inflammatory bowel disease (IBD), or the possibility of colorectal cancer, they must immediately seek medical care. Receiving a timely colonoscopy or endoscopy is essential to developing an individually tailored treatment plan to help the patient recover.
Although such services are critical for diagnosing and monitoring disease progression, many Americans face delays and denials due to insurance company practices that disrupt patients’ access to the medically necessary care needed for GI conditions like IBD. One particularly onerous mandate and detrimental insurance barrier is prior authorization, which allows insurers to overrule a physician’s clinical decisions by delaying—or often denying—patients’ access to the health services prescribed by their trusted GI doctor.
Prior authorization has become a systemic tool that insurers use to control costs. A recent report from the American Hospital Association found that nearly two-thirds of patients experienced insurance coverage-related barriers like prior authorization within the last two years. Moreover, according to a 2022 American Medical Association survey, four out of five doctors say that prior authorization leads patients to abandon their recommended course of treatment at least some of the time, which can lead to significant adverse health impacts. In fact, 25% of doctors say delays caused by prior authorization have led to a patient’s hospitalization. Insurers must stop prioritizing profits over patient health.
Insurers frequently require prior authorization before approving prescriptions to treat patients with IBD and GI conditions, in particular. Physicians are often required to switch a stable IBD patient to a new medication because the insurer negotiated a better price, even if the physician disagrees that the new medication will be as effective. The process for appealing delays and denials can be lengthy, confusing, and cumbersome, requiring physicians to hire multiple full-time staff dedicated to managing the prior authorization process. Ultimately, many patients give up.
When required for routine services like colonoscopies and FDA-approved drugs for patients with serious chronic conditions, like IBD, prior authorization goes directly against the standard of care. When I treat patients with IBD, the FDA-approved drugs that are indicated for treatment often require a prior authorization review, yet if I prescribe the steroid prednisone—a medication that is not the standard of care for IBD because it is not effective—most insurers don’t require a prior authorization review at all. They allow the lower cost prednisone without batting an eye. This is unethical and it’s common. According to a study published this month in the American Journal of Gastroenterology, insurers almost always denied coverage of biologic drugs as a first line of treatment, instead requiring patients to fail steroids and immunomodulators first. This runs counter to clinical guidelines. In fact, adherence to American College of Gastroenterology/American Gastroenterological Association guidelines ranged from 5.8% to 58.8% among the nation’s 50 largest insurers and less than 17.65% of policies permitted biologic therapies for IBD patients without first failing other, less expensive, medications.
The impact of prior authorization can be devastating. Consider the case of GI patient and law student Chris McNaughton, who was denied treatment by his insurer, UnitedHealthcare (UHC), for his debilitating ulcerative colitis that left him with fatigue, anemia, arthritis, and life-threatening blood clots. His insurer’s egregious use of prior authorization eventually ended in a lawsuit, and a 2023 ProPublica investigation revealed employees at UHC mocking Mr. McNaughton, misrepresenting critical findings, ignoring warnings from his doctors about changing his treatment plan, and being more concerned about the money Mr. McNaughton was costing them rather than his health and wellness. These types of cases, extreme as they are, happen every day. I fear they will become more common if insurers like UHC succeed in implementing prior authorization policies for critical GI services, including diagnostic and surveillance colonoscopies and endoscopies.
Any delay in care due to insurance coverage is dangerous. For obvious reasons, insurers would never hold up treatment for pneumonia or hemorrhaging, so why do they do it when patients with IBD have severe flare-ups, which can be just as serious? It doesn’t make sense.
To help promote accountability, transparency, and ethical policy development, the American Gastroenterological Association (AGA) recently published a white paper outlining a comprehensive plan for improving IBD care and fixing the insurance barriers plaguing our healthcare system. It recommends that independent review boards be established to ensure insurance coverage policies are evidence-based, patient-centered, and based on clinical best practices. These boards should include patients and medical specialists (for example, gastroenterology experts in IBD) to help regulators and health plans review any policies that may have bias, lack evidence, or don’t adhere to standards of care. Moreover, independent review organizations should be required to review appeals if a patient’s prescribed care is denied, and the prior authorization process should be streamlined. In cases where prior authorization requests are denied and appealed, there should be standard of care reviews done by a “like” physician (e.g., a gastroenterologist with experience in IBD) instead of someone like a pediatrician or dermatologist, as is all too common now. Finally, health plans should publicly report data on rates of initial denials, appeal denials, and response times for accountability.
As a gastroenterologist who has witnessed first-hand how prior authorization prevents my patients from receiving necessary treatments and screening for GI conditions and IBD, I’m confident that my patients would benefit from more ethical insurance policies and a national appeals process.
Insurers should immediately end their overreach into medical decision-making and work with medical providers and their patients to ensure timely care for all. It’s time for payers to listen to the voices of the medical community and help us expand, not threaten, vital access to care. By ensuring comprehensive coverage for essential monitoring and medications and upholding patient-centered care principles, our leaders can make IBD and GI care accessible, equitable, and effective for all patients.
Photo: sorbetto, Getty Images
