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- Prior authorization?
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Good evening, 66.1ers.
A patient died the other day. Of course, this sort of thing happens when you’re working with people battling cancer. Doesn’t make it easier, just makes it expected. But this one was different.
Patient was dealing with pulmonary hypertension in addition to their cancer. Dr. Google tells us that pulmonary hypertension means that the plumbing in the lungs is narrowed, meaning that the heart has to work harder to get blood to the lungs. The heart works harder, harder, harder until it fails. On the way to heart failure, the patient is increasingly short of breath. Ugly.
There’s pulmonary rehabilitation (re-training your lungs) and certain medications that can help, and the patient was using both to address what was going on.
Sadly, at the time of their death, this patient was waiting on approval of a prior authorization from their insurance company to get a refill for their medication. Not familiar with the term? Gemini will help!
Here’s the story in a nutshell: patient needed a refill of their medication for pulmonary hypertension. Doctor wrote the prescription but it didn’t go through. Patient tried to do some stuff to get the prior authorization to go through, no luck. Sent some messages to the doctor asking for help. Doctor jumped in to help. Patient also shared that they were increasingly short of breath, is this normal? Should we be worried? It’s been a week since the last dose, using more oxygen, can you please help?
The next day, patient’s daughter sends messages to everyone on the patient's care team. Patient passed away yesterday afternoon, please cancel all appointments.
So that’s it. Pharmaceutical company created the solution to the problem, put a price on it. $12,000 for a 30-day supply, according to my research. Insurance company knew the solution existed, patient had benefitted from taking that medication twice in the past. But $12,000/month is a lot of money, so prior authorization was required. Unfortunately, while the patient was navigating this stuff with their heart doctor, they ran out of time.
Doesn’t it make you wonder how many people every year die while waiting for insurance to approve the medication that could save their life?
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