Doctors say the stakes are highest in cancer care, when delays can be the difference between life and death.Angela Pike’s husband, Tracy, had just celebrated his 45th birthday when he was diagnosed with Stage 4 stomach cancer. A father of three and the maintenance chief of a Louisville, Kentucky, skyscraper, Pike immediately started chemotherapy, which reduced the size of the tumor his doctor had discovered.
Angela said the last straw came when she learned that one of the insurer’s physicians who had rejected the treatment was not a cancer doctor at all. He was an obstetrician-gynecologist. In January 2024, Tracy Pike died, leaving behind his wife of 22 years and their three children. Last year, 17 % of Americans reported that their insurance company had denied coverage for care recommended by their physician, , a nonprofit that supports research on health care issues. More than half said they and their doctor did not challenge the insurer’s denial.
“Nowhere are the stakes higher than in cancer care,” he said, “where delays can literally be the difference between life and death.” conducted by the American Society of Clinical Oncology, a network of 50,000 cancer professionals, found that 42% of prior authorizations were delayed by more than one business day and that 14% of the delays resulted in a “serious adverse event for a patient.”
“We walked out of the room with what we thought was an agreement,” said Scott, the organization’s president. “But since then, there’s been no action. Since that togetherness we had with them, things have gotten worse.” “I remember when it was experimental,” Sumrall said. But today “it is routinely practiced,” she added, “and for some people is a huge lifesaving procedure.”
Clockwise from top left: Angela and Tracy Pike in a 2001 photo; the creek where Angela spread some of Tracy’s ashes; a tattoo on Angela’s arm in his handwriting.Health insurance companies say that requiring doctors to justify the procedures they recommend saves money. For example, Cigna says prior authorization can cut the costs of expensive treatments and prescriptions by requiring patients to try lower-cost alternatives.
“There need to be responsible ways to use prior authorization,” Pratt said in an interview. “It has gotten quite out of hand. I think of it as patients on a journey and prior authorization is like hurdles along the way that they may not be able to progress past.” in 2021 known as the Gold Card Act, which exempted physicians from going through the authorization process if private insurers have approved their procedure submissions at least 90% of the time.
Raghu said this shift is particularly surprising because it is occurring during the same year that the Food and Drug Administration began to notify patients with dense breast tissue that they may need additional cancer screenings. Those additional screenings include MRIs and ultrasounds for which Medicare is denying coverage.
Raghu pointed out that there is only one reimbursement code for a breast ultrasound, regardless of whether it is proposed as a screening or a diagnostic test. As a result, the routine denials by Medicare this year appear to place all breast ultrasounds into the category that is not covered. In response, she began aggressive immunotherapy treatments with quarterly PET scans to monitor her metastatic breast cancer. Hsu has continued working and gave birth to her daughter, who is now 4 years old.Hsu estimates that over the past three years, she has spent roughly 40 hours a month fighting for reimbursements from health insurance companies whose coverage was offered through her workplace.
Hsu said her physician told her that Cigna considered the PET scan unnecessary because she has been cancer-free for five years. But because Hsu’s cancer is metastatic — it spreads — she and her physicians consider a PET scan necessary to monitor for evidence of new cancers.
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Fuente: NBCNews - 🏆 10. / 86 Leer más »