Anyone living with or caring for a loved one with a chronic condition knows that finding an effective treatment is only half the battle. Unfortunately, there is also a constant battle with insurance companies to make sure they continuously cover treatment.
Living with diabetes, I’m often forced to deal with the unnecessary and dangerous barriers insurance companies impose on patients and their health providers. One of the biggest obstacles is the opaque, time-consuming and unpredictable process by which insurance companies approve or deny claims.
Thankfully, Colorado lawmakers are considering a bill this year to improve this process by making some much needed reforms to prior authorization — the process by which health insurers require prior approval before determining if they will cover a prescribed procedure, service, or medication. House Bill 1149 will prevent lapses in care caused by prior authorization and make this process more transparent. The prior authorization process is unnecessarily burdensome and complicated, causing delays in care and taking important health decisions away from physicians and patients. This can have a huge impact on our health and our lives — something I’ve had to experience firsthand.
I recently accepted a new job with competitive pay and what is considered excellent health insurance coverage. As I got settled into my new career, I was shocked to find out that my health insurance company denied a claim for one of my two medications for diabetes. For years, this medication had been successful in treating my diabetes and keeping my blood sugar levels stable, and my doctor had been satisfied with the results. Despite multiple doctors appealing the claim denial — a highly bureaucratic process that costs time and resources that should be directed toward patient care — the insurance company rejected it.
This forced me to choose between paying $900 a month for my medication — an expense very few people, including me, can afford — or putting my health at risk. The health insurance company came up with their own solution. They told my doctor she should just increase my other medication. That’s right — someone working in health care claims, someone with no medical training, told my doctor what to prescribe. I had no choice but to stop taking the medication that for years had been keeping me stable.
As a trained nurse, I was well aware of the alarming warning signs in my body. My blood sugar spiked to dangerous levels, sometimes to 400 or 500, putting me at risk for heart attack and stroke. I began to worry that my husband might find me unconscious.
Unfortunately, my story is not unique. In a recent survey from the American Medical Association, about 1-in-5 physicians said that prior authorization policies led to a life-threatening event or required intervention to prevent permanent impairment or damage. These are unnecessary medical risks that endanger people’s lives. They also disproportionately impact those with lower incomes; according to KFF, lower-income adults were three times as likely to see a decline in their health due to insurance issues like prior authorization requirements.
It’s unacceptable that prior authorization essentially allows insurance carriers to practice medicine when it’s doctors who have the direct medical knowledge, training and experience as well as the direct contact and conversations with their patients to determine what treatment, procedures and medications are best. While doctors have a vested interest in ensuring patients access the treatment they need, private health insurers have a vested interest in denying access to that care. In fact, a report from ProPublica found that one insurance carrier automatically rejected claims without ever reading them by using an automated system that spends just 1.2 seconds on each claim.
We need to speak out against this profit driven system that puts life-altering medical decisions in the hands of insurance companies and their algorithms. Bureaucracy and red tape should never stand between patients and care they need to remain healthy. As this bill has advanced out of the House and is now with the Senate Health and Human Services committee, I ask that all Colorado lawmakers support House Bill 1149.
Margaret Comstock lives in Pueblo and is a community organizer at the Center for Health Progress with 34 years of experience in the health/medical field, including nine years working in public health.
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