Jeffrey S. Barkin, MD, DLFAPA, is a practicing psychiatrist in Portland and the former president of the Maine Medical Association. He co-hosts “A Healthy Conversation” on WGAN.
On a recent weekend, I prescribed a cheap generic medication for one of my patients. That sentence should not be interesting.
A patient came for help. A physician evaluated the problem. A common medication made sense. The drug was not exotic, experimental or expensive. It was the kind of ordinary medicine Americans assume will be available when a doctor believes it is needed.
Then the insurer demanded prior authorization.
For readers lucky enough not to know the term, prior authorization means this: before a patient can receive a treatment, an insurance company or pharmacy benefit manager may require the doctor to prove that the treatment is necessary. In theory, this is supposed to prevent waste. In practice, it often turns doctors into unpaid clerks and turns patients into people waiting for permission to get care.
This time, the medication was a cheap generic. The administrative process costs more than the drug. That is not cost control. That is absurdity. More than that, it is morally wrong.
I found myself asking permission to do one of the most basic things a physician does. I was not asking for luxury care. I was not trying to bend the rules. I was trying to prescribe an inexpensive medication to a patient who needed treatment.
That moment clarified something for me. I may be done prescribing medication.
Not done caring. Not done evaluating. Not done diagnosing. Not done helping other clinicians make good decisions. But done being trapped in a system that makes a physician responsible for refills, denials, pharmacy problems, prior authorizations, appeals, after-hours messages and insurance obstacles that I did not create.
Doctors should not have to choose between caring for patients and having a life. Patients should not have to wait because an insurance company built a gate in front of a medicine that should have been available the same day.
Prior authorization was once defended as a limited tool for unusual situations: very expensive drugs, dangerous combinations or treatments where careful review might prevent real harm. But that argument collapses when prior authorization is used against stable medications, inexpensive generics or treatments a patient has already been taking safely.
At that point, prior authorization is no longer protection. It is obstruction.
A stable medication should not become unstable because an insurer changes paperwork. A cheap generic should not require a physician to spend part of a holiday weekend proving it is necessary. A patient who has done well on a treatment should not be thrown into anxiety because a company decided the doctor must again justify the obvious.
For stable or inexpensive medications, routine prior authorization should be considered morally unacceptable. Not annoying. Not inefficient. Not merely bureaucratic. Morally unacceptable. Why? Because the harm is predictable.
It delays care. It frustrates patients. It drives some people to give up. It wastes clinical time. It forces doctors and staff to spend hours proving what the medical record already shows. It turns healing into a paperwork contest. It rewards the organization that creates friction and punishes the patient who needs help.
The American Medical Association recently reported that 95% of physicians say prior authorization delays access to necessary care, 79% say patients abandon treatment because of authorization problems and 26% say prior authorization has led to a serious adverse event. Those numbers should end the debate.
This is not just a doctors’ complaint. It is a patient safety issue.
In psychiatry, delay can be especially harmful. When someone is depressed, anxious, sleepless, panicked, irritable, traumatized or barely holding on, a week is not just a week. It can mean another week of not sleeping, missing work, drinking too much, fighting at home or wondering whether help will ever arrive.
The moment a patient agrees to treatment is often fragile. Trust has been built. Fear has been addressed. Hope has appeared. Then the patient is told: wait. An insurer must approve what your doctor already recommended.
The language of insurance makes this sound harmless. “Utilization management.” “Prior authorization.” “Step therapy.” “Medical necessity review.” These phrases are designed to sound calm and responsible. But patients experience them differently: delay, confusion, embarrassment at the pharmacy counter, extra phone calls, lost confidence, paying cash or going without.
Physicians experience them as something else: the slow theft of professional life.
Every prior authorization asks the doctor to stop being a doctor and start being a claims processor. Stop seeing the next patient. Stop calling the family. Stop thinking. Stop documenting. Stop resting. Stop being present at home. Log in. Fill out the portal. Wait on hold. Send the note. Repeat the history. Appeal the denial. Argue with someone who does not know the patient and may not practice in the same field.
This is why doctors burn out. And this is one reason patients cannot find doctors.
When experienced physicians leave direct care, reduce their hours, stop taking certain patients, stop prescribing, stop accepting insurance or retire earlier than planned, we act as if it is mysterious. It is not mysterious. If the job becomes less about healing and more about begging for permission, people eventually leave.
Prior authorization survives because doctors keep rescuing patients from the cruelty of the process. We hate the system, but we complete the forms. We are angry, but we make the calls. We know the burden is unreasonable, but we do the work because the patient is suffering. That compassion is being exploited.
Insurers and pharmacy benefit managers know that the physician is the one who has to face the patient. The doctor hears the fear. The doctor worries about relapse, withdrawal, deterioration, hospitalization or suicide. So the doctor absorbs the burden. Again and again.
At some point, physicians must say no. Not no to patients. No to a broken game. No prior authorization for inexpensive generic medications. No prior authorization for medications a patient is already taking safely. No repeated approvals for stable chronic treatment. No anonymous denials by reviewers who are not true peers. No unpaid physician labor for administrative obstacles created by insurers. No delay without accountability when delay harms a patient.
These are basic rules of decency.
Right now, the system has it backward. The insurer creates the barrier. The patient suffers the delay. The doctor donates the labor. The company keeps the savings. That arrangement should offend anyone who believes in fairness.
I want to care for patients. I also want time with my wife, my children, my grandson and my family. I want to practice medicine without surrendering every weekend, holiday and quiet hour to an insurance maze. I want young doctors to enter medicine without inheriting a system that treats their judgment as suspicious and their time as free.
Prior authorization for stable or inexpensive medication should become indefensible. No insurer should defend it. No legislator should tolerate it. No patient advocacy group should ignore it. No physician should have to apologize for opposing it.
We do not need another polite conversation about administrative burden. We need a declaration of independence from a process that has become harmful, wasteful and cruel.
A cheap generic prescription should not require a battle. A stable medication should not require repeated permission. A doctor should not have to beg to practice medicine.
Prior authorization, as now used for ordinary and inexpensive care, is not reform. It is not stewardship. It is not patient protection. It is a moral failure. It should end.