Excellent video. And once again, Dr. Prasad makes himself a target by telling the truth.

I just had an MRI prescribed by my doctor denied TWICE by insurance this last week. Evidently big insurance knows what is best for me more than my personal doctor.

As physician, the frustration occurs largely because treatment protocols mandated by insurance carriers do not always follow the science. What mystifies most of us is who writes their protocols governing the allocation of care. Compound that with the mystery about how treatment protocols required by insurance carriers are generated. Then, we must deal with reviewers who most likely have never treated a patient or the actual condition at hand. This is to say nothing of peer-to-peer conversations which can be even more frustrating. The "peer" doesn't even work in the same specialty as the one requesting the care. I understand the need to ensure requested care falls with acceptable guidelines, but there is a stark difference between guiding healthcare delivery and interfering with it.

25% of my job as a PA now is about prior auths or peer to peers. They deny everything unless it meets an arbitrary algorithm. It’s not medicine

Funny you brought up the self implosion of the Roman Empire - we're headed in the same direction but healthcare is the least of the worries at the moment.

prior authorization is a crazy way to manage care. there are lots of complaints about a national health plan some other countries have, but prior authorization and insurance companies beating you down with bureaucracy is generally much worse. yes, you might find some oddball cases where doctors are picking unproven unwarranted treatments, but everyone knows plenty of cases when prior authorization and out of network treatments just lead to excuses from companies that have way more bureaucracy and time to waste than patients and people give up and get frustrated with trying to get insurance to pay for completely warranted treatments

I watched a story about how insurance companies are outsourcing prior authorizations, and they reward the companies who maintain a 50% denial rate. So what happens is a double amputee needs a wheelchair, and bc his doctor didn’t include how being a double amputee affects his ability to walk (I can’t even….), he was denied a wheelchair. So the doc resubmits the request, and he was granted a wheelchair on the second one. This counts as two separate patients-TWO-even though it’s the same person. So that company gets to report a 50% denial rate. An amputee being delayed in getting a wheelchair may not kill him, but what happens when it’s a treatment for an aggressive cancer? Ppl die before it gets approved. It’s pure insanity. I get that there are two sides to this, but it’s also true that the insurance companies employ a business model that says “deny, delay, defend”, and it’s costing ppl their lives, or at the very least their quality of life.

Thank you for this! I'm so impressed with your willingness to post an honest view of the prior auth situation, even knowing most of your viewers disagree and you might lose some. I really appreciate your continued fairness and nuanced discussions of all these issues.

Thumbs up for Vinay having the courage to speak truth! I hate insurance companies for the many problems they have caused me as someone 52 years of Type 1 diabetes. Forcing me to switch from a brand of insulin that works for me to a brand that doesn't to save $5 bucks via a middleman discount makes no cents (pun fully intended). But I totally agree that in the real world of medicine more than a few procedures waste of medical resources partially due to incompetence and partly due to maleficence. This video says more about the NYT than it says about health malfunction. Their journalism is getting worse and worse and worse and their circulation a d page count is getting smaller and smaller and smaller. Worse yet they apparently aren't even reading their own newspaper because Elizabeth Rosenthal, one of their own columnists, has repeatedly exposed the cost + 20% clause, most recently in her definitive book "An American Illness." Anyone truly wishing to understand the roots of the high costs and poor outcomes of American medicine should read her book which explains in great detail the numerous causes of both.

As a MRI Tech who has to help Prior Auth get pushed through for outpatients I appreciate your balanced and nuanced take because I feel the same way. Some referring physicians refuse to learn anything about Radiology even though we try to educate them and they order the most unindicated and frivolous MRIs for the wildest differential diagnosis eliminations. In my opinion its doing the patients more harm than good with both the financial and emotional hit of doing such a procedure (MRI is very hard on patients). On the other hand I've called physicians directly begging them to consider doing a Peer2Peer appeal to Prior Auth denials based on the prior imaging evidence and many will refuse because its too much work even though we have compelling evidence their patient has a cancer. It is so incredibly frustrating to me to navigate this broken healthcare system, moral hazard and injury for all - all around - all the time.

Thanks for shining light on the other side of this debate.

I'd love your take on the WPATH files. I think it's another example of ideology being more important than data and what's best for patients.

My father got a liver transplant. He was given hepatitis C during the Vietnam era in the army, as many of the servicemen were, but didn’t find out they had it until they were very sick. Gave me 10 more years with him.

For your non hospital listeners - a simple clear example of “this is the process of prior authorization” would be useful.

As a pharmacist, I hate prior authorisation. My patients think I’m denying them. Terrible.

Thank you for this. I worked for three different health insurance organizations (all of them not-for-profit orgs) going back to 1996 and the bill that became HIPAA law and, later, when the PPACA was passed in 2010. It's hard to explain to people that insurance can never pay for everything a doctor or patient wants, because it would fail in about a week. The fact that health insurance exists at all, and that (until recently) most people were priced out of it unless they were covered under a workplace group plan, is an accident of history. It's a highly imperfect system, and certainly for-profit orgs have an incentive to wring more money out of patients, but it is not and cannot be a free smorgasbord for every unproven or questionable treatment one can imagine. I appreciate you pointing that out and injecting common sense into the discussion. People imagine there must be a malicious human who looks at every claim and declares "yes" or "no" based on their mood that day, and that's just not how it works.

As a patient advocate, I often request authorizations (many Drs don't bother or don't know how). If the treatment is "serious", deemed expensive, or is long-term, 2 supportive medical opinions, proof of "standard of Care", history of failed traditional options and inclusion by medical policy are the minimum needed to present a case. I worked in oncology for 6 years, and you're right, the only treatments denied were off-label and even many of those were authorized if listed in the NCCN. What seems to be denied a lot these days are treatment or therapy by out of network providers, "last-ditch" measures without trying less aggressive and more conventional measures and (of course!) IVIG. The rate of denials has been getting worse, even for extensions of existing authorizations for tx proven beneficial, safe and medically necessary.

I nearly lost my colon because of the delays with prior authorization. The medical schedulers and insurance people really put me in a bad place. I eventually had to check myself into the emergency room and get hospitalized before I could receive an expensive medicine called Remicade. -Although this medicine is expensive, it worked miraculously on me. There needs to be some sort of improvement to the system....

I was the person in the video that went blind. I didn't need medicine, I needed emergent surgery. I have Idiopathic Intracranial Hypertension. I needed to see a neuro-ophthalmologist for an ONSF to prevent my optic nerves from being crushed. The medical group refused to send me outside of their network (they didn't have a neuro-ophthalmologist in network). My doctors and I fought for more than 12 weeks to get that authorization, and by that time my optic nerves were crushed. I've been legally blind since 2008 because of it. ONSF and VP shunts are the gold standard for this condition when medical management has failed and vision is compromised. All of the boxes that needed to be checked were checked. Why? Because they didn't want to have to pay for the specialist and hoped I would leave the group instead of demanding care. Because of them, I ended up disabled for 10 years while I learned how to live and function again... while being a single parent to a small child. The system is BROKEN.

I've had a swollen cervical lymph node on the back of my neck that the insurance won't allow scans of for years. Also, my pops was denied a heart cath only to find out he had a 90% blockage after ending up in the ER.

The whole point of an insurance company is to deny coverage and price gouge.

Dr V - do a video of the lunacy of the ASP + 6% model of reimbursement. I worked for the company that launched the first bio-similar G-CSF and the consultants said we had to charge MORE than the branded molecule to sell any of it - because the physicians would choose the higher priced option since it would mean slightly more profit. Hard to control costs when physicians are incentivized to choose the most expensive option!

Was in the work comp business for 30 years. Part of my career was responsible for approving or denying TX. Believe me I saw some wacky recommendations. Many unnecessary surgeries, esp spine. Feel like I saved lot of people . In WC we were able to direct patients to best possible MDs for 2nd opinions tho.

The obsession with health insurance & the resultant excessive regulation has lead to a separation of the providers & patients from the cost of the product itself which is healthcare. This has made health insurance itself the primary product, which no thanks to government regulation is shielded from normal economic forces of demand & supply.

Retired midwife here, have worked in 3 countries. Agreed. Keep up the good work!

Always enjoy your perspective Dr. I learn alot.

PA is needed due to our perverse system that separates doctors and patients from costs. In my experience The percent of doctors who are naturally interested and competent in cost benefit analysis is about 1.

I"m so glad you posted this. When I clicked based on the title, I was waiting for a diatribe about how onerous the process is, and to be fair, for some treatments, and especially with some insurers, it's a nightmare. As a person who has filled these out, I've had the headaches. As a patient waiting for the treatments, believe me, those headaches get amplified by the fact that you're unwell and this is your hope on the line. But as you rightly point out, someone's got to watch the piggy bank. We have a broken healthcare system that disconnects the guy whose bank account gets drained from the decision to spend. The responsibility for weighing the value of a treatment is transferred to the doctor who's suppose to inform the patient but often does a half-..ssed job of it, and to the insurer who has no personal stake at all in the decision and only cares about the bottom line. When you have people with different agendas and motives making the decisions instead of the guy who actually has to pay the bill, we need someone to step in and be the patient's voice, not just his voice of desperation (the doctor) and not just his voice of reason (the insurer). We need both to prevent waste and quackery. Yes, the process should be streamlined, efficient, and transparent. Yes, we should have an appeals process. I can't think of any insurer that doesn't do these things with their PAs. They're a necessary evil, so if they need reform, use a scalpel and not a sledgehammer.

OMG I am in awe of you Dr Prasad. You are a hero for speaking the truth and honesty.

I’m a NP in IBD at a large center in NYC and 75% of my job is prior auth denials/appeals. 50% of the time the denial is for ON LABEL expensive biologic medications because the insurance “prefers” and alternate first line. sometimes the alternate they recommend isn’t even for IBD! Insane

Dr P! Excellent content! It is very alarming how big pharma, food and tech seem to keep us unhealthy and in need of their assistance! 6 year carnivore and all need for medicines are gone! Take your life back people!

It’s not always preauthorisation….. mine was pre op is not needed….. my Dr and the facility thought therefore it was covered. NOPE. Went to Nebraska Insurance appeals 5x….. we got an attorney and ended up paying between the medical bills and legal fees …..$35,000! THANK YOU BLUE CROSS BLUE SHIELD!!!!

Great topic and you have shed more light on this complicated subject for me, thank you!

This is a fundamental dilemma built into third party payment. Where there is no prior authorization (original medicare with medigap) all kinds of procedures are done with little cost justification. Where there is managed care, prior authorization saves the insurance company at the expense of the patient. Some of the worst abuses arise in medicare advantage. Where there is no third party payment, the patient may not be able to afford beneficial care. The US seems to manage this dilemma especially poorly.

Love your analysis, VP.

Time to start a parallel system don’t you think? Many doctors are doing that already.

What happened to journalism that sought to present multiple sides of complex topics like this? I so rarely hear both sides of this issue, but you’re exactly right. Hopefully there’s a solution to these problems somewhere, but it’s not as simple as commonly presented as “insurance denying care to make money.”

Saying we spend it on healthcare though in itself is a misnomer because we're spending it mainly on sick care. People who have done nothing to be healthy all their lives and then we spend exorbitant amounts of money trying to save them from their poor decisions. I'm not saying people don't deserve any care when they're sick at all, but our focus is on sick care, not health and until that changes the problems we face won't change

I have also seen frequent cases where the insurance company recommends a medication that actually failed clinical studies and could not get FDA approval because there’s one positive article somewhere in their compendium of evidence while denying an efficacious treatment. This was most specific to mental health.

That's a perspective I haven't considered well thought out and argued

As an old RN that also did case management I had the benefit of talking by phone to insurers to solve some of my pts problems. But as a pt needing surgery, I came up hard against what my pts experience. I waited to get approved for my surgeries only to be told all was approved and scheduled. One got cancelled night before because ooops no authorization obtained I was told. The other time 6 months AFTER my gall bladder surgery...I get bills saying insurance denied it. Took months of dealing with the pt phone lines with over seas call centers not understanding my complaint and escalation before I had to make a complaint to state and things got settled. I no longer trust any Drs office OR the phone calls to determine authorizations. I document every call, every name, as I would for my own pts. Can't assume anyone is doing their job and documenting on their own end anymore.

And more gov control of healthcare would be more of this and worse.

Pragmatic Prasad… Thanks for your quest to push healthcare towards evidence-based medicine. IMO reasonable people who want to make rational decisions should embrace the spirit of your videos

It certainly seems endless to our government…

At Kaiser Permanente in Southern Calf the MDs get the treatment that is prescrobed

As someone that has lupus, MS, SRDS, SPS or also known as SMS, RA and many many many other autoimmune disorders that tags along. Years ago when I was told I could keep my insurance…I was dropped! Now I pay out of pocket for everything! Now I do get as many grants as possible and do TONS of studies (lab rat) just to stay alive. Thankfully I’ve been blessed with a few fantastic docs that REALLY work with me and only give an RX that they think may help. Still though, I run into many docs that try to push something that scares me or I can’t find any research to back up me spending 1000-2500 on a script. Oh how I wish that I could be your pt! Also I’ve had Cervical cancer quite a few times…We’re still chipping away! It sucks! But it is what it is when you have to be the decision maker and pt. Bless you for helping people understand and bringing awareness to so many important things! 💜🙏💜

Wow!! Didn’t know about the medical loss ratio under the affordable care act. Great info

Nothwithstanding its reputation for socialised medicine, Australia has a significant private healthcare system funded largely through individuals purchasing insurance on a voluntary (albeit tax incentivised) basis. Our insurers are passive payers - if a hospital/doctor puts a claim in, the insurer pays it. Obviously there are integrity processes, but there's no right of veto (outside of agreed policy coverage). The insurance is becoming unaffordable. Govt tries to supress premiums. Insurers try to squeeze doctors and hospitals. Something has to give.

It's started here in Canada too.

Insurance companies have found a way around ACA loss ratios. They bought out PBM's, so when they pay for prescriptions, they are paying themselves and skewing the ratios. That's why the "market" prices for drugs are insanely overinflated.

As a pharmacist, I totally agree. My go to example which is a major headache, but reasonable are prior authorizations for certain opioid regimens (especially when oxycodone isn’t combined with buprenorphine). There may be a valid reason to do it, but there needs to be a plan to get the patient off of them quickly. With everything a provider has to deal with, it is too easy to just send in another prescription for a pain medication rather than the multiple conversations with the patient about how long term use will likely be more worse for the patient.

Thanks for your insight -- especially the "Whackadoodle" unproven remedies.

Excellent nuanced take on a complex topic. Out of control healthcare spending could bankrupt our entire nation.

Keep speaking up.

Hi Dr Prasad, would you consider doing a deeper, more nuanced vid about prior auth? In family practice we seem to spend inordinate time on it both at the initial notification/filing of as well as the front desk handling numerous angry calls from pts. Many times it is a medication pt has been on long term but insurance changed. Abruptly stopping a blood pressure medication can cause big problems, 911 and ER visits. Fangirl since Covid w you and ZDogg. Thanks for all you do to enlighten and inform.

It cannot be stated more forcefully how important this video is to the deep rooted problems in healthcare. The more you spend the more you make.

As a pharmacist who works for insurance, specifically in the Medicare space, I can tell you that there are medical directors on board who sign off on criteria. It's also usually a medical director who sign off on appeals decisions. The insurance companies don't blindly make criteria. It's evidence based and, yes, you are correct. There are way more doctors prescribing things inappropriately than you think. And it's really Medicare who dictates these things. If we approve something that shouldn't have been approved, Medicare doesn't reimburse us and we end up losing money in that sense.

Really appreciate you breaking that down. Wish we'd been able to keep right to try, still, though. I think that was a good, at the very least, temporary solution. Love ya! XOXO

A lot of people have responded to points you made in the video. I wanted to add another wrinkle. For capitated insurance models (eg Medicare Advantage), it truly does save insurance money to deny care. And MA plans are notoriously bad about denying care for medically indicated treatments.

YES MORE VIDEOS ABOUT THE INSURANCE MODEL AND TALK ABOUT THOSE DOCTORS WHO STEP OUTSIDE OF THE SYSTEM LIKE DIRECT PRIMARY CARE.. THANKS

Ah... The prior authorization boondoggle. As a licensed acupuncturist, I've have long wanted U.S. healthcare to become cash-based, except for accidents and emergencies. When it comes to chronic health problems drugs and surgeries are rarely helpful and often hurtful. Rather, diet and lifestyle improvements combined with functional medicine modalities are the way to go. Currently in my 18th year of practice.

this is what RFK calls 'corporate capture' where industries take over their relative governmental agencies, in this case, health care being controlled by big pharma and the health insurance lobbies...

Let Vanderbilt pay for the lung tx

True story. When I was doing my pathology residency we had someone request a unit of platelets on a patient with a very mild (over 100K) platelet count. When asked why the patient’s physician said, “I don’t want any abnormal values on their CBC.”

Great commentary. As a former insurance regulator who was NEVER in the insurance industry, I found that insurers are no more likely to take advantage of customers than customers are to take advantage of insurers. It seems that no one, including, and not surprisingly, the NYTimes editorial board, remembers that insurers can only cover what they take in via premiums, which are set by guesses about future usage; when usage goes up, so do premiums, so it's to everyone's benefit to keep usage low. The problem is that some time in the past it was believed that people had insurable interests in their own health, which they wouldn't try to damage any more than they'd try to kill themselves, burn down their homes or crash their cars, and that doctors were NOTHING like body shops and would never think of turning up the gas on costs because they had medical oaths. Oh well.

How would you design the system if you could? Should insurance companies use randomly selected panels of doctors or medical scientists to evaluate treatments that aren't previously authorized?

The discussion always returns to the theme of overutilization in healthcare. The percentage of GDP spent in this sector will continue to ratchet up unless economic incentives are dissociated from medical education with a rigorous plan. The hard truth is that the policymakers are bought out and many don’t even know it.

"timely authorization " may have to be legislated in the near future

It is unconscionable that in this day and age, and in one of the most wealthy countries in the world patients can die simply for not having enough money in their pocket. This is madness.

My Medicare Part D actually changed my cardiologist’s prescription. Cigna prescribed for me, refusing outright the medicine my doctor prescribed. They said the two drugs were similar, not identical. The drug the insurance company wanted me to take is not available in doses that suit my small, sensitive and old body. I thought doctors prescribed and insurance companies did other work. I was wrong. I pay $80 a month for this coverage where the insurance company decides I have to take a larger dose of a different drug.

The insurance didn't want to give me a MRI.....

I don’t want any bureaucrat with the insurance industry second guessing my doctor who actually saw me, touched me, talked to me. Period

What nobody seems to want to discuss is, the USA spends more on healthcare but has a less healthy population when compared to other economically advanced countries (virtually all other developed countries, I believe). How can this be? Could it be that we devote most of the massive healthcare spending to cure and very little to prevention, and particularly, much stronger promotion of healthy life styles? Yes, we have far fewer smokers but we also have an obesity epidemic, the long term consequences of which are probably as bad or worse. Even the US military is having trouble finding young recruits who can pass a physical. All indications are that this sad state of affairs is likely to continue. After all, there is far less money to be made from a healthy population. Why encourage a healthy life style when you can make a buck giving someone an injection, essentially for life, instead of maintaining a healthy diet that involves exercise? As always in the USA, follow the money.

I need a hip replacement but I’m too young and get hip injections to buy me some time. I completely understand that they have to watch the procedures but they take it too far and use the denial process routinely. Every time in my case and my doctors have to appeal. Causes me approximately a month of excruciating pain every 6 months. (I’m basically allergic to pain medication and only take it for actual surgeries). They have all the records, they know it works and yet they still play this game.

Thanks for talking about something other than Covid!

My “Prior” Authorization” for a cardiac catheterization was DENIED a WEEK after the procedure! It took reaching out to every level of approval to get it approved-unnecessary stress Aetna !!

This is why I ALWAYS select high deductible option. Keep your premiums as low as possible. Save the max every year in an HSA. If you need medical care and your insurance won't pay, you will be in a good position to negotiate a cash price for your procedure here in US or other any other preferred country!

My husband is a type II diabetic. He had success on trulicity a few years ago. He lost weight and was able to wean off all diabetic medication. We now have a child and have slowed down and his sugar and A1c have slowly crept back up. Our insurance is now denying trulicity ozempic and mounjaro which are due Eric medications. But my two friends who are in a weight loss program can get ozempic no problem. Make it make sense. I’m over here panicking with his hyperglycemia and insurance is giving out his medicine for vanity instead of to him who needs it.

The problem with "no prior authorization" (for example, in a PPO) is that an insurance denial coming months later into a recurring course of treatment can leave a patient/family on the hook for many thousands of dollars when an up-front denial would have given them a good chance to re-think the treatment options.

they made more things more expensive not more support

Your right only use medicine with prior history. Not like we have ever found multiple uses for 1 medication…. WTAF?

Thank you for giving a more objective idea of the process, regardless of personal opinion of PA (I hate it too). My one objection: Yes providers likely prescribe non-scientific regimens, but shouldn’t other physicians be the ones to decide/govern if it should be covered? Especially since these insurance companies aren’t verifying lack-of-coverage with medical professionals.

I want Ubrelvy for migraines. Other Triptan meds don't work, which is what insurance required me to try first. Between my insurance company and the "requirements " needed (that have changed from one triptan, which I took, to another triptan) ,and my doctor's PA representative screwing it by either not doing anything or sending insufficient info up for MONTHS, I have waited over a year and still don't have PA. Ridiculous.

I have ok insurance but for the most part I cant touch it for my stage 4 cancer. See I chose not to go the Chemo/surgery route to battle this as prescribed. I seen three family members pay a terrible price. My estimation is that the treatments killed them faster than the original disease. Their quality of life was not good. The medical establishment has made great strides in diagnosing cancer but the success rate numbers havent changed in 50+ years. The treatment protocol is a dinasaur and they know it. The new treatment protocols are junk. So my alternative options are directly out of pocket. I strongly believe that my chances of survival are equal or slightly improved. I guarantee that my quality of life is a lot better off. We dont need this healthcare system as much as they have led us to believe. Thats my rant.

This is why I'm glad I live in Australia because we don't need any "prior authorisation", plus the Australian health system is NOT run for profit it's run on the idea that the patient gets better no matter how much it costs to the insurer.

Thank you Vinay. There needs to be checks and balances. But holy cow they have got to improve the prior authorization system. The peer to peer reviews are ridiculous because the "peer" at the insurance company usually doesn't even have a clue about the specialty. It's not a "peer".

Guess what, the new plan they are going to do is use AI and basically just reach in and grab the info from the doctor's office and review the prior auth based on the patient's chart info. Yes, there will still be times the doctor will be required to call in and those very few and far between wonderful doctors who care about their patients will fight to get them what they need. And the ones who don't have time or don't care will not do anything as usual. This will decrease the amount of prior auths that are denied. Just so you know, even though it may be a pain in the a$$, no matter what if you submit an appeal and continue to say that it is medically necessary they will approve it bc going by what they say, whatever the doctor says is "Golden." To answer another question you mentioned, you're correct they do not get paid more to deny prior auths. However, it is sickening on what the real reason is. It's the insurance companies treating the patient's like lab rats. A group of pharmacists for each insurance company (this is for prescriptions not medical) decide what medications will be covered and a broker basically selects these benefit options for commercial insurance plans and same for Medicare each year but the pharmacists come up with these lists they will offer and the broker selects them each year. I noticed for Medicare they switch things around every year which I think is ridiculous but if you say it is a continuation of care they may deny it once but resubmit it and they should approve it. I don't think the elderly should be forced to try these new drugs that get approved but that is basically what is going on. It's a racket for the drug manufacturers. By these insurance companies making these selections each year and changing the plan options they force the members to try different drugs by making the drugs they were on exclusions. But trust me when I say re-submit as a continuation of therapy even if it's the same info, resubmit and sometimes submit chart info with it and they will approve. Please let your doctor friends know and the AI will be used coming this year to reach in and grab the info so only the denials will need additional assistance. I'm kinda on the fence about it but they already get the info anyways so I imagine it should help.

Know take this same logic and apply it to education

As a long-time "prior auth" patient who has to ultimately spend more money and time to "prove" I have something evidentially wrong going on, I do still have some empathy that too many doctors gave too many people unnecessary things. Those 5% of us whose complaints always get proven by labs/xrays will keep on rolling with the punches, eventually getting the answers our drs want. I do sometimes fantasize, though, about getting our TSA version of healthcare - get through the line with serious background checks, proving we neither demand anything (simply tell a doctor a complaint), and it always leads to something seriously wacky.

I take your point but why am I having to do prior auths on a 15 dollar medication for insomnia that has been around for 30 years?

I agree with everything you said. But, I think that we should get a score. If your useless test ratio falls below a certain point, you don’t have to do PAs until your 6 month recalc. I rarely do expensive stuff because there are usually better options, but occ I need the expensive thing and then it’s just painful.

This is nothing new. I used to have to obtain P.A.s for patients starting treatment for Hepatitis C (back when Peg Intron and Rebetol was the best treatment). The treatments were denied at least 50% of the time.

The age when “drs give patients what is needed” is over. Drs give patients what the medical authorities and pharma allow them to give patients. We have learned that over the last 4 years.

I'm not a "professional" and I never belonged to a union or association like lawyers and doctors. As a result, I suffered with low income employment, without "organized labor" to improve my income. Are doctors and lawyers "too expensive," and isn't it the expense that insurance companies don't like? If a lung transplant only cost $10,000. would insurance be more likely to pay some lower sum? How much does a pacemaker "installation" cost in USA? In Canada, I received a pacemaker "free of charge," but is the cost to government to pay doctors "too high" and some doctors quit the system because they want higher income, and run to USA where a good doctor can fleece everybody with million dollar services.

Just changed insurance to PPO because a referral back over a month ago has not been approved as of this date. PC doctor says I need the care.

There are people who will die because the insurance company doesn't believe the treatment is worthwhile when the insurance company and doctors who work for them are not informed enough to understand the treatment or the illness. Goes both ways when it all comes down to doctors not being educated enough to be responsible for people's lives and insurance companies never being in business to help people.

Thanks for the balanced discussion. I would also hate prior auth and pre-cert, but as you said, there a lot of stupid prescribing and a lot of “shut up medicine.”

I just love when you have to get prior authorization of a generic medication. Even worse, when it’s been an indicated medication the patient has been on for years.

One of the issues is the cost to get a clinical trial in the medical field for off label usage. While I agree the evidence can be lacking for extreme procedures it's because they are generally rare enough that no one can justify the cost. This is something I've been noticing for a while. The barrier to entry in almost wll avenues has become to high. FAA, Medicial, Law, and more. We have gotten to the point where we're not progressing because of these systems. At this point the government is going to have to start offering massive grants for innovation.

Okay, as a physical therapist, requiring prior authorization, every two visits for continued care post-operatively starting at the beginning is Just a way to stress us out and add extra stuff to our plate and does nothing to help the patient at all. And I'm talking to you. Blue Cross.