fostering the humanistic practice of medicine publishing personal accounts of illness and healing encouraging health care advocacy

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fostering the humanistic practice of medicine publishing personal accounts of illness and healing encouraging health care advocacy

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Two dreaded words for medical providers and patients: Prior Authorization (PA). For the fortunate few who have not needed to engage in this process, here’s a definition from the American Medical Association website: Prior authorization is a health plan cost-control process by which health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

From a patient’s point of view, a PA is needed when the medication or procedure recommended by their provider is not covered, and they must go back to their provider and engage in a process that feels as nebulous as outer space. From a provider’s perspective, the patient does not receive the care they need and now loads of paperwork are required to complete the care plan. To summarize: everyone is miserable.

This paperwork entails fine-tooth combing through the patient’s chart to prove that they “failed” first line (read: less costly) treatment. If this information is not available, because the patient never tried the meds or the records are elsewhere, the patient must try these less expensive treatments (read: less effective), delaying treatments that could benefit them greatly. During this delay their health may worsen or they lose time pursuing and finding a diagnosis to explain their symptoms.

One of the hottest medications is Wegovy – a medication used to treat diabetes, now approved for chronic weight management. We primary care providers see countless now-hopeful patients who have struggled with obesity and obesity-related complications, making appointments to discuss Wegovy. After years of the medical establishment blaming symptoms and health issues on obesity (read: the patient), now the medical establishment is trying to be part of the solution!

Well… not for everyone. For patients on Medicaid, it is virtually impossible to get Wegovy approved – even with the PA. Commercial insurances approve Wegovy with a PA. People with Medicaid often live in food deserts and neighborhoods without safe outdoor spaces, and often work several jobs to pay the bills, and thus lack discretionary time to go to the gym or meal prep or get adequate sleep. For BIPOC folks with Medicaid, this especially feels like one more insult.

We medical providers must break this news: Wegovy is not covered by insurance and is prohibitively expensive. We can offer other medications that are less efficacious. At these appointments, I watch the faces of my patients fall, and I share in their frustration.

Pamela Adelstein
Newton, Massachusetts


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