Seven-year-old Megan* was ready to go home. She had been hospitalized with a bone infection for over a week, requiring intravenous antibiotics and an emergent surgery. Her condition had markedly improved, and she was excited to cheer on her dance team in person. The only problem—she could not swallow pills, and her insurance would not cover the liquid medication she needed.

As I sat down to explain to Megan and her mom that she would have to stay another night in the hospital while we submitted a medication prior authorization, I saw the excitement in Megan’s eyes turn to frustration. The insurance company was unresponsive, so our only option was to try to teach Megan to take a pill for the very first time. In a hospital full of cutting-edge medical technology, I found myself going to the vending machine to get Megan a packet of Skittles. We tried for a long time—the nurse, Megan’s mom, and I—to teach Megan to swallow the candy like a pill. But the pressure of the situation proved too much, and Megan had to spend the night in the hospital—her appeal sitting in the fax machine of an insurance company closed for the weekend.

Megan is one of many children who has had their hospital stays prolonged due to prior authorization, a policy that hurts patients and cedes medical decision-making to insurance companies rather than providers. Prior authorizations require healthcare providers to submit a request for a medication, procedure, or hospitalization before the insurance company will authorize coverage. In some cases, the requests can be submitted electronically and are approved or denied the same day. But other times, the requests must be submitted by fax or by phone. After the request is submitted, the insurance company can take an unregulated amount of time to approve or deny the request. On the Cigna Prior Authorization webpage, the company states they will respond to prior authorization requests within “5-10 business days.” For a child waiting in the hospital for a medication to take home, that time frame is unreasonable.

Drug Formularies Drive What Medications are Covered

The requirements for a medication prior authorization are dependent on an insurance policy’s drug formulary—a list of medications that insurers deem appropriate for coverage. The creation of drug formularies is an opaque process that differs from plan to plan, but cost containment plays a large role. Unfortunately, most common medications are more expensive in liquid form. A search on GoodRx shows that liquid nitrofurantoin, an antibiotic, is $2300, nearly forty times the cost of the capsule version. In addition, the liquid formulation of famotidine, a common antacid, is $153, double the cost of the tablets. Unfortunately, these restrictive drug formularies disproportionately effect children who are either too young to swallow pills or have complex medical needs requiring liquid medications via a tube.

In addition to the cost and distress associated with a prolonged hospital stay, there is growing evidence that prior authorizations lead to patient harm. In a 2021 survey by the American Medical Association, 93% of surveyed physicians reported that prior authorizations delayed access to necessary care and 24% of physicians stated that a prior authorization has led to a patient’s hospitalization. A recent study by pediatricians from the Children’s Hospital of Colorado revealed that prior authorizations delayed the initiation of appropriate treatment for pediatric inflammatory bowel disease by approximately 12 days.

Prior Authorizations are Increasingly Prevalent

Prior authorizations are increasingly prevalent. The American Medical Association found that on average, physicians complete 41 prior authorizations per week—putting patients like Megan at risk for delayed care far too often. D.C. Councilmembers have recently introduced  B25-0124, the Prior Authorization Reform and Amendment Act of 2023, that would require insurers to provide patients with their rationale for a prior authorization, set a regulated timeline for insurers to resolve prior authorization requests, and prohibit prior authorization requirements on the basis of cost. I urge DC Councilmembers and Mayor Bowser to support this vital piece of legislation that takes important steps forward in making the prior authorization process fairer for patients.

Megan missed her team’s dancing competition waiting for her medications, even though her doctors cleared her to go home. We need our lawmakers to act now so that children’s healthcare can be decided by their medical team and not by their insurance company.

*Name changed to provide patient privacy. Patient mother provided permission to use patient story in this op-ed.

The author would like to thank Dr. Jessica Weisz, CHAI Affiliate Faculty, and Elizabeth Davis, CHAI Manager of Government Affairs Manager, for their helpful review of this post.