We see it more and more – patients have to fail multiple therapies before they may finally begin the one actually recommended by their physician. Often that means the patient has to endure a period of discomfort, pain, or disability – what we might call “pain and suffering” before the right therapy may be commenced. The delays in this scenario aren’t due to physicians’ errors, or even insurance requirements that less invasive interventions prove failures. Instead, Pharmacy Benefit Managers often delay therapy for the sake of profits.

Typically, a patient may have to navigate this step-by-step process of ruling out the ineffective therapies before the patient gets the right one. Alternatively, clinic staff can secure a prior authorization to bypass the lengthy trial and error period (that the physician has already deduced would be futile and cause unnecessarily, and perhaps, harmful, delay). The result is that physicians and their staff spend an average of thirteen hours a week on preauthorizations, and almost all of them report patient care was delayed by the prior authorization process. A whopping one third report that waiting for these prior authorizations caused a severe adverse event, such as a hospital admission (24%) and nearly one in five had a patient endure a life-threatening event or intervention to prevent permanent impairment or damage. Tragically, 8% of physicians report that these delays have led to a patient’s disability or permanent body damage.

This system is an unnecessary drain on the clinic, who has to have a staff member take time away from patient care to jump through insurance hoops. Forty percent of physicians report they have staff who work exclusively on prior authorizations. And nearly all physicians, 88%, describe the burden associated with prior authorizations as “high” or “extremely high.” These PBMs are for-profit businesses, whose model involves the business of selecting acceptable medications to treat patients – based not on its effectiveness, but instead cost savings for the PBM. While these PBMs seek to save money, and generate returns for investors, patients may find themselves hospitalized due to, say, inability to access necessary asthma medication.