Page 9 - Delaware Medical Journal - May/June 2019
P. 9
PRESIDENT’S PAGE
ANDREW W. DAHLKE, MD
MSD President Andrew W. Dahlke, MD is a Neuroradiologist who practices with Southern Delaware Imaging Associates in Lewes.
The Human Cost of Prior Authorization
As health care professionals, we have all seen the harm to patients caused by a prior authorization process that is out of control. The process is random, frivolous, and Kafkaesque.
In January 2019, the California Supreme Court let stand a lower court verdict United Healthcare (UHC), the nation’s largest health care insurer.1 levied by the state health commissioner because of actions carried out by a UHC
the California Insurance Commissioner
was to “weaken consumer protections to allow insurers to escape liability when they intentionally deny expensive but life- preserving medical care.”
In November 2018, an Oklahoma jury
family of Orrana Cunningham, stating she was recklessly denied proton beam therapy to treat stage 4 nasopharyngeal cancer that was adjacent to the brain stem.2 Aetna claimed the therapy was investigational and experimental. The family started a GoFundMe campaign patient lived another year and passed from a viral meningitis. Scans prior to her passing showed the tumor shrinking. Proton beam therapy was covered by Medicare at the time of the Aetna denial, yet considered experimental by Aetna.
Yarushka Rivera of Lowell, Massachusetts was able to get Topamax for seizures without preauthorization until June 2009. When she turned 19, MassHealth would no longer cover the drug without going through the pre-authorization process.
The pharmacy (Walgreens) told the family
not have. Yarushka Rivera died at the age related to a family’s inability to understand and navigate the overly complex and unnecessary pre-authorization process.
Why should a patient be denied a medication that they were previously The family attempted to sue Walgreens and was unsuccessful. The case was tried three times and reached the Massachusetts Supreme Court.4
When Kate Weissman was denied proton beam therapy by United Healthcare,
her parents dipped into their retirement
for treatment targeting metastatic retroperitoneal lymph nodes. The UHC doctor that denied her care was an OB/ GYN, but was not boarded in gynecologic oncology. Mrs. Weissman was cancer- free two years following the proton beam treatment.5
John Emerson, a Pittsburgh construction manager, fell and injured his shoulder.
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