IHP 430 Milestone One Guidelines and Rubric
An organizational problem within the health insurance industry is the use of prior authorizations. Prior authorizations are a utilization management process used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication. The problem with this practice is that it could take days for the provider to get a response from the insurance provider which leaves the patient at risk by not being able to obtain the services or medication that the provider is suggesting may ultimately save that patient's life. The idea that the insurance company knows best and not the provider is potentially putting the patients in harm's way. Insurance companies use this method as their way of gauging if the medication or procedure is truly medically necessary. The claim is that this helps to keep healthcare costs down and helps to prevent unnecessary costs. The problem is that following this idea decreases patient satisfaction and has been found to put approximately 26% of patients at high risk due to the length of time that had to wait for approval for either their prescription or procedure. There is also a practice that insurance companies use when it comes to prior authorization for prescriptions, where they want you to try several different step therapy medications before they allow the drug your provider is prescribing to be covered. This is very dangerous for some patients specifically AIDS
patients for example, who undergo several combination drugs before the correct combination may be discovered for them. Changing one drug is likely to allow low-level resistant variants to mutate and become more resistant to medication by doing this (Infectious Disease Advisor 2017). This also impacts patient satisfaction, patient safety, and patient readmission rates during their wait for a prior authorization.
