Prior Authorization: A Barrier to Mental Health Recovery

"You mean, your doctor can prescribe something and then your insurance can just say I'm not covering that?"

I glanced hopefully at the brochure a doctor at a study center handed me last year. They felt this medication could make a real difference for me. I've tried a lot of medications and while the medication I received in the study had helped me, it's not yet available. The recommended medication wasn't on my insurance formulary, so I tried something else. It wasn't as effective. My provider was supportive of the other option. I spoke with my insurance, receiving assurance that after a prior authorization, the medicine could be added to my formulary. Yet, a few days later, I'm waiting with anxiety for confirmation that I can get my medication.

Prior Authorizations

Prior authorization is a cost-saving measure insurance companies and other payers take to avoid covering expensive medical options when lower-cost alternatives are available. It looks like this; someone receives a prescription for a medication or service, they try to fill it at a pharmacy (or reach out to the program), and the pharmacy or other provider receives notice that insurance requires prior authorization. The pharmacy then reaches back out to the provider who is then tasked with some combination of phone calls, forms, and faxes to make the case that an individual meets the payer's criteria to access it (such as medical necessity, appropriateness, and/or having already received other, usually lower cost, treatments the insurance deems as 'steps' before covering this one).

It's a lot.

Across medical disciplines, practices such as these have been criticized for reducing access to necessary health services and taking medical decisions out of the hands of providers familiar with the patient. A 2017 survey of physicians found that 90% indicated that the process had a significant negative impact on patients (American Medical Association, 2017).

Mental Health

When it comes to mental health, prior authorization requirements may exist for any number of treatments. Most commonly, these are required for medications, or a higher level of care such as residential or intensive outpatient treatment. Still, at times prior authorization is required even for traditional psychotherapy.

This is troubling. A level of strength is needed to reach out for mental health care. In addition, unlike many conditions, certain mental health challenges are associated with anosognosia. Anosognosia is a neurological phenomenon wherein a person loses the ability to recognize their illness. For example, it is believed to affect 57-98% of people diagnosed with schizophrenia to one degree or another (Lehrer and Lorenz, 2014). When additional barriers are added to getting help a person who greatly needs it but does not know they do may be even less likely to receive it.

A study of individuals living with bipolar disorder who received Medicaid benefits found that prior authorization requirements on medication correlated with discontinuation of medication and decreased engagement with mental health services (Lu et al., 2011). Another study found that individuals with mental health conditions who struggled with accessing medication due to drug coverage were 73% more likely to have an emergency room visit and had a 71% higher number of days spent in inpatient hospitalization (West et al., 2010). In addition to the clear, quality of life issue, this data regarding high-cost services suggests that contrary to its cost-saving mission, prior authorization of mental health medications or services may ironically increase health costs.

National mental health advocacy organizations including Mental Health America have issued position statements in opposition to many payer practices that limit access to medications including step therapy (also known as fail-first policies) which require individuals to attempt treatment with a list of alternative medications before a specific medication can be prescribed. This practice restricts opportunities for individuals to receive the treatment their doctor may have reason to believe would be best for this particular person. It also removes the possibility for many who could benefit from receiving the most cutting-edge treatments, which often are branded and not listed as 'preferred' medications.

Managed care requirements have also been referenced as inciting difficulties for individuals with eating disorders in accessing a higher level of care, such as residential treatment, when indicated as well as for discharge before the clinical team and individual feel that a lower level of care is necessary. Also, related cost-saving measures such as utilization reviews by insurance companies regarding individuals receiving psychotherapy compromise confidentiality and dissuade psychotherapists from accepting insurance in fear of 'clawbacks' (when a payer requires money spent on a service be paid back due to determining some criteria was not met). This has effectively reduced access to psychotherapy among individuals hoping to use their insurance benefits disproportionately affecting groups more likely to be paying for services with insurance or other managed care including BIPOC populations (Minsky-Kelly and Hornng, 2022).

While it is possible to advocate for an appeal of a decision to not approve a treatment one's provider deems as necessary under the Mental Health Parity and Addiction Equity Act, the process can be daunting. For a person struggling with significant mental health symptoms, this can feel impossible.

In Conclusion

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Healthcare is complex. Mental healthcare is especially so. While abandoning managed care constraints on healthcare altogether might be unrealistic, the harm done must also into account. When it comes to mental health, individual treatment decisions are best made between a provider and their client. Policies that prevent access to vital mental health services interrupt individual recovery journeys. Reform of prior authorization requirements in mental health care is desperately needed.