Health insurance companies should not be making medical decisions
Health insurers are endangering patients’ lives. Every day, they wield prior authorization not as a safeguard but as a bureaucratic weapon — delaying vital, life-saving treatments and overriding expert decisions of medical professionals. The consequences of these delays are devastating, and I have seen them firsthand.
Consider my patient who had a life-threatening skin cancer. Despite surgery, chemotherapy, and radiation, the cancer aggressively returned. In consultation with a team of oncologists, radiation specialists, and surgeons — following the National Cancer Center Network guidelines (one of two sets of guidelines used around the world) — we determined immunotherapy was the best course of action. The insurance company disagreed.
Seven days after submitting the request, the claim was denied. I was given the opportunity for a peer-to-peer appeal, but given only a 48-hour window or the treatment would be permanently denied. I spent hours navigating the insurer’s labyrinthine system to argue my case. A non-oncologist on the other end dismissed our decision, refusing to disclose who denied our decision and which guidelines the insurer used. A second appeal, even with a supporting letter from the Chair of the NCCN Squamous Cell Carcinoma guidelines supporting my treatment plan, was again rejected noting that the insurance company’s internal experts disagreed with the Chair interpretation of the guidelines (that he wrote and approved). The insurer would only approve a toxic, ineffective chemotherapy. Desperate, I secured the immunotherapy for free from Bristol-Myers Squibb. Two treatments later, my patient has a great response and is cancer free today.
This is not an isolated case. I saw a young single mother with an aggressive but curable form of breast cancer. I requested the top NCCN-recommended treatment. After weeks of waiting, it was denied — by an insurance representative who was neither a doctor nor a cancer specialist and was looking at the WRONG set of guidelines for a different cancer. When I corrected her, she insisted I was wrong. Knowing time was running out, I spent precious days working on getting the free drugs. That woman is now cured and raising her children, alive because I circumvented an arbitrary, broken system and got her the treatment she needed.
These cases are just a fraction of the battles I fight. I spend hours every week entangled in prior authorization disputes, diverting time and energy away from patients who desperately need care.
Insurers claim they are protecting patients from inappropriate treatments. In fact, they are obstructing evidence-based, expert-recommended care, ultimately delaying life-saving care. In the cases above, insurers misinterpreted medical guidelines, overruled expert recommendations and, at times, rejected all FDA approved treatments. In the insurer’s eyes, the treatments I had recommended above would be considered inappropriate according to their internal experts and propriety guidelines. The insurer’s interference blocked patients from receiving care that was not only appropriate but crucial for survival — care unanimously supported by treating physicians and national experts. Instead of protecting patients, insurers used their influence to deny life-saving treatments, often without transparency or accountability.
I heard an insurance industry representative say they help to improve the quality of care that patients receive citing a case where a doctor recommended an expensive targeted therapy to a patient with metastatic breast cancer who had underlying cardiac issues. I do not know the details of the case, but I do know that targeted therapy has a 5% chance of causing a reversible cardiac injury but can prolong an individual’s life for years. Refusing targeted therapy for this patient may save her a potential 5% risk for a reversible heart injury but gives her a 100% chance of dying from her cancer in the next 12-18 months. To me, reviewing the risk and benefits of individualized treatment plans is the purview of the treating doctor. The choice is the patient’s. When insurance companies wield prior authorization power in this way, they are in essence practicing medicine and making decisions for patients.
Health insurance companies should not be making medical decisions. Prior authorization has become a mechanism for rationing care, prioritizing corporate profits over patient survival. The question is simple: do you want your doctor or your insurance company deciding your fate? If the answer is your doctor, then it is time to demand legislative action to end this dangerous practice. Please support NC Cares First Act (HB 434), a bipartisan bill sponsored by health care professionals that would put care decisions back into the hands of patients and their doctors.
Martin Palmeri is a medical oncologist at Messino Cancer Centers.
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