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My 97-year-old blind mother slipped into dementia last year and now requires full-time assistance in a memory care unit. Her long-term care insurance carrier insists on three-month care updates for continued payment, even though she will never improve. I empathize with Kim and Kinsley Munson, the examples in Sunday’s editorial on prior authorization (“Don’t let red tape burden patients,” March 31).
Despite my personal experience, I am opposed to legislation that exempts PA for categories of medical care. The Legislature does not have the expertise to make medical management decisions. Too often lawmakers write laws based on anecdotes that result in disastrous unintended consequences.
For example, the proposed law exempts cancer therapy from PA on the assumption any delay will be deadly. The wrong therapy can be even more deadly.
From 2005 to 2018 I managed the UnitedHealthcare oncology department. My team noticed a progressive surge in the usage of erythropoietin, a drug that prevented the need for blood transfusions in chemotherapy patients. In the era of transfusion-related HIV infections, this medication was a lifesaver, but HIV testing was commonplace by 2005, so manufacturers promoted the therapy to alleviate fatigue. The drug had a dark side. When it was administered to patients who already had reasonable blood levels it could cause strokes and heart attacks. It also accelerated cancer recurrences in several studies. The FDA issued a black box warning in 2007 stating that no one with a hemoglobin level above 12 (a measure of anemia) should receive the drug.
Our research found that in 300 consecutive patients receiving erythropoietin more than one-third were being treated incorrectly. A PA was started immediately. The Medicare program copied our program six months later because of the safety issues.
In another example, UnitedHealthcare policy paid for any chemotherapy drug that was recommended by the National Comprehensive Cancer Network (NCCN), a coalition of the best cancer centers in the United States. The company did not use PA, but it did review the claims after treatment to ensure that they matched the NCCN guidance. For four successive years, approximately 7% of those treatments were not compliant. Those patients were getting the wrong drugs — losing precious time and an opportunity for a response. It is important to note that these errors occurred in almost every oncology office in the nation; they were not caused by a few bad actors.