When getting to the doctor or picking up a prescription is not as simple as running to the corner, dealing with a treatment delay or denial caused by your insurance company can be a major nuisance
When getting to the doctor or picking up a prescription is not as simple as running to the corner, dealing with a treatment delay or denial caused by your insurance company can be a major nuisance. In rural areas, where patients already have fewer choices when it comes to healthcare coverage, the tactics health insurers use to control treatments and cut costs can be real barriers that prevent patients from easily accessing the healthcare they need.
Over the past several decades, insurance companies have developed a series of cost management strategies, often referred to as utilization management (UM) protocols, to better control their healthcare expenses. While these tactics are sometimes necessary to reduce unnecessary treatments or protect patients from the potential side effects of new drugs, some insurers are imposing them too aggressively and restricting patients from accessing certain providers, procedures and medications. The restrictions can be particularly onerous for rural patients.
According to a new report on patient access from the Doctor-Patient Rights Project (DPRP), the most direct way insurers are denying coverage is through formulary exclusions. Each year, insurance companies—usually through their pharmacy benefit managers (PBMs)—release lists of the medications, procedures and treatments they will cover in the next coverage year, and at what level. About 5 years ago, the nation’s biggest PBMs also started issuing formulary exclusion lists, announcing all the treatments they absolutely will not cover unless they are deemed absolutely necessary by a doctor requesting an exemption.
Since the genesis of formulary exclusion lists, PBMs have rapidly expanded the number of excluded medications and procedures. In a nationwide survey DPRP conducted earlier this year, roughly one in four respondents (up to 53 million patients) reported having been denied coverage for prescriptions to treat chronic or persistent conditions. Roughly 37 percent of the denied patients DPRP surveyed said they were denied coverage for the prescribed treatment because it was excluded from the insurer’s formulary. Formulary exclusions were by far the most common justification for denying treatment coverage.
Prior authorization requirements are another common insurer cost-cutting strategy. Under this practice, doctors are forced to contact the insurer, submit pages of documentation justifying their treatment decisions and wait for the insurer’s reply before prescribing the chosen treatment. All of the paperwork not only costs doctors money, but precious time they could be spending treating patients. Nearly half of doctors report that they, or a member of their staff, spend 20 hours or more each week on prior authorization activities. One in four doctors report spending more than 40 hours a week on authorizations, according to a survey by the American Medical Association.
Most patients denied treatment for a chronic or persistent illness wait at least a week just to receive a denial of coverage. Twenty-eight percent of the denied patients DPRP surveyed earlier this year said they waited three weeks or longer.
Although DPRP’s survey results did not break respondents out by where they resided, I would bet that the many of the denied patients who waited the longest for an authorization were from rural communities. Rural patients are less likely to be covered by Medicaid, have employer-based coverage or prescription drug benefits. And even though 20 percent of Americans live in rural communities, less than 10 percent of physicians practice in these areas, according to data from the Stanford School of Medicine. When a single insurer and a handful of providers are the only options in your area, you take what you can get.
On top of limited choices, rural residents must tackle greater travel distances, geographical barriers, extreme weather, rough road conditions and a lack of public transportation just to access their healthcare services. When insurance companies add administrative hurdles that often require multiple visits to the doctor, it is no wonder that rural patients often give up on treatments or are more likely than others to stretch their prescriptions by reducing dosages.
Rural Americans—like all Americans—pay their health insurance premiums and deductibles expect quality healthcare in return, not insurance company protocols that make access even more difficult.
Cheryl Elias is the Executive Director of the U.S. Rural Health Network, an organization dedicated to creating and maintaining a dialogue between national health care advocates and rural communities.