Prior authorization may hinder access to lifesaving heart failure medications

(Press-News.org) Prior authorization, a process that requires physicians to obtain approval from health care insurers before certain treatments are covered, may keep patients from filling prescriptions for two critical heart failure drugs, a new study shows. 

Led by NYU Langone Health researchers, the analysis focused on angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors, which are pillars of modern heart failure treatment. The drugs have no generic alternatives and can cost hundreds of dollars out of pocket. While they have been shown to substantially reduce the risk of death when added to standard therapy, past research showed that less than half of patients prescribed these medications take them regularly. 

According to the new study’s findings, people with heart failure whose prescriptions required prior authorization took three times as long to fill an ARNI prescription and six times as long to fill an SGLT2 inhibitor prescription than those whose prescriptions did not require it. Patients whose SGLT2 prescriptions required prior authorization were twice as likely to never fill them. 

“Our results suggest that prior authorization may be doing harm when it comes to guideline-recommended medications with no generic alternatives,” said study lead author and cardiologist Amrita Mukhopadhyay, MD, “While these policies are meant to control health care costs by steering patients toward lower-priced alternatives, they may instead be keeping people with heart failure from timely access to lifesaving treatments.” Mukhopadhyay is the Eugene Braunwald, MD, Assistant Professor of Cardiology in the NYU Grossman School of Medicine’s Department of Medicine and its Leon H. Charney Division of Cardiology.

According to the authors, delays and nonfilled prescriptions may occur because most patients fill prescriptions the same day as their medical visit. If the pharmacy tells them they must return weeks later, some may give up on the treatment. Clinicians might also hesitate to prescribe a drug if they know it will require prior authorization, adds Mukhopadhyay, who is also an assistant professor in the Department of Population Health at the NYU Grossman School of Medicine.   
    
The current findings echo those from interviews and surveys of physicians and patients that have long suggested that prior authorization requirements can delay care, increase treatment abandonment, and erode trust in the health care system, Mukhopadhyay notes. 

Published online Jan. 27 in the journal JACC: Advances, the study is the first to examine the impact of prior authorization on access to ARNI and SGLT2 inhibitors prescribed for heart failure and to provide clear evidence that it may significantly delay their pharmacy fills, the researchers say. 

For the investigation, the research team assessed information from the electronic health records and pharmacy fill logs of 2,183 men and women in treatment for heart failure at NYU Langone Health. All had received a new prescription for ARNI or SGLT2 inhibitor between 2021 and 2023. 

For each patient, the team determined whether prior authorization was required and how long it took to fill the prescription within a year of it being written. The researchers accounted for patients’ race and ethnicity, gender, education, and other demographic and social factors in their statistical analysis. 

The findings revealed that prior authorization was more common among people living in lower socioeconomic-status neighborhoods and among those who identified as Black or Hispanic. Patients facing these prior authorization requirements were also more likely to have Medicaid insurance. According to the researchers, this suggests that these policies may be reinforcing health care disparities. 

“Our results indicate that prior authorization requirements may be contributing to the substantial health disparities seen in heart failure care and need to be carefully reexamined,” said study senior author Saul Blecker, MD.

According to Blecker, an associate professor in the NYU Grossman School of Medicine’s Departments of Population Health and Medicine, the study team next plans to explore how copays, coinsurance, and other elements of insurance may affect access to heart failure drugs. 

Blecker cautions that the findings may not be easily generalized to the entire country since the study assessed patients within a single health care system. Because New York state Medicaid offers some of the most comprehensive coverage policies in the nation, the barriers linked to prior authorization may be even higher in other states. 

National Institutes of Health grants R01HL155149, R01HL152699, K23HL171636, and K24AG080025, and the American Heart Association and the New York Academy of Medicine, provided funding for the study. 

Along with Mukhopadhyay and Blecker, NYU Langone and other NYU researchers involved in the study are Samrachana Adhikari, PhD; Xiyue Li, MS; Adam Berman, MD, MPH; Carine Hamo, MD; John Dodson, MD, MPH; Rumi Chunara, PhD, MS; Nathalia Ladino, MS; Harmony Reynolds, MD; and Stuart Katz, MD. 

Other study co-investigators are Dhruv Satish Kazi, MD, at Harvard Medical School in Boston, and Ian Kronish, MD, MPH, at Columbia University in New York City.

Reynolds has received funding for unrelated research from biotechnology companies Abbott, Philips, and Siemens. NYU Langone Health is managing the terms and conditions of these relationships in accordance with its policies and procedures.

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About NYU Langone Health
NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. Vizient Inc. has ranked NYU Langone No. 1 out of 118 comprehensive academic medical centers across the nation for four years in a row, and U.S. News & World Report recently ranked four of its clinical specialties number one in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across seven inpatient locations, its Perlmutter Cancer Center, and more than 320 outpatient locations in the New York area and Florida. The system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise.

Media Inquiries
Shira Polan
212-404-4279
Shira.Polan@NYULangone.org 

 

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