Marine Corps veteran Ron Winters clearly recalls his doctor\u2019s sobering assessment of his bladder cancer diagnosis in August 2022.<\/p>\n

\u201cThis is bad,\u201d the 66-year-old Durant, Oklahoma, resident remembered his urologist saying. Winters braced for the fight of his life.<\/p>\n

Little did he anticipate, however, that he wouldn\u2019t be waging war only against cancer. He also was up against the Department of Veterans Affairs, which Winters blames for dragging its feet and setting up obstacles that have delayed his treatments.<\/p>\n

Winters didn\u2019t undergo cancer treatment at a VA facility. Instead, he sought care from a specialist through the Veterans Health Administration\u2019s Community Care Program<\/a>, established in 2018 to enhance veterans\u2019 choices and reduce their wait times. But he said the prior authorization process was a prolonged nightmare.<\/p>\n

\u201cFor them to take weeks \u2014 up to months \u2014 to provide an authorization is ridiculous,\u201d Winters said. \u201cIt doesn\u2019t matter if it\u2019s cancer or not.\u201d<\/p>\n

After his initial diagnosis, Winters said, he waited four weeks for the VA to approve the procedure that allowed his urologic oncologist at the University of Texas Southwestern Medical Center in Dallas to remove some of the cancer. Then, when he finished chemotherapy in March, he was forced to wait another month while the VA considered approving surgery to remove his bladder. Even routine imaging scans that Winters needs every 90 days to track progress require preapproval.<\/p>\n

In a written response, VA press secretary Terrence Hayes acknowledged that a \u201cdelay in care is never acceptable.\u201d After KFF Health News inquired about Winters\u2019 case, the VA began working with him to get his ongoing care authorized.<\/p>\n

\u201cWe will also urgently review this matter and take steps to ensure that it does not happen again,\u201d Hayes told KFF Health News.<\/p>\n

Prior authorization isn\u2019t unique to the VA. Most private and federal health insurance programs require patients to secure preapprovals for certain treatments, tests, or prescription medications. The process is intended to reduce spending and avoid unnecessary, ineffective, or duplicative care, although the degree to which companies and agencies set these rules varies<\/a>.<\/p>\n

Insurers argue prior authorization makes the U.S. health care system more efficient by cutting waste \u2014 theoretically a win for patients who may be harmed by excessive or futile treatment. But critics say prior authorization has become a tool that insurers use to restrict or delay expensive care. It\u2019s an especially alarming issue for people diagnosed with cancer, for whom prompt treatment can mean the difference between life and death.<\/p>\n

\u201cI\u2019m interested in value and affordability,\u201d said Fumiko Chino, a member of the Affordability Working Group for the Memorial Sloan Kettering Cancer Center. But the way prior authorization is used now allows insurers to implement \u201cdenial by delay,\u201d she said.<\/p>\n

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Cancer is one of the most expensive categories of disease to treat in the U.S., according to the Centers for Disease Control and Prevention<\/a>. And, in 2019, patients spent more than $16 billion out-of-pocket on their cancer treatment, a report<\/a> by the National Cancer Institute found.<\/p>\n
To make matters worse, many cancer patients have had oncology care delayed because of prior authorization hurdles, with some facing delays of more than two weeks, according to research Chino and colleagues published in JAMA<\/a> in October. Another recent study found that major insurers issued \u201cunnecessary\u201d initial denials<\/a> in response to imaging requests, most often in endocrine and gastrointestinal cancer cases.<\/p>\n
The federal government is weighing new rules<\/a> designed to improve prior authorization for millions of people covered by Medicare, Medicaid, and federal marketplace plans. The reforms, if implemented<\/a>, would shorten the period insurers are permitted to consider prior authorization requests and would also require companies to provide more information when they issue a denial.<\/p>\n
In the meantime, patients \u2014 many of whom are facing the worst diagnosis of their lives \u2014 must navigate a system marked by roadblocks, red tape, and appeals.<\/p>\n
\u201cThis is cruel and unusual,\u201d said Chino, a radiation oncologist. A two-week delay could be deadly, and that it continues to happen is \u201cunconscionable,\u201d she said.<\/p>\n
Chino\u2019s research has also shown that prior authorization is directly related to increased anxiety among cancer patients, eroding their trust in the health care system and wasting both the provider\u2019s and the patient\u2019s time.<\/p>\n
Leslie Fisk, 62, of New Smyrna Beach, Florida, was diagnosed in 2021 with lung and brain cancer. After seven rounds of chemotherapy last year, her insurance company denied radiation treatment recommended by her doctors, deeming it medically unnecessary.<\/p>\n
\u201cI remember losing my mind. I need this radiation for my lungs,\u201d Fisk said. After fighting Florida Health Care Plans\u2019 denial \u201ctooth and nail,\u201d Fisk said, the insurance company relented. The insurer did not respond to requests for comment.<\/p>\n
Fisk called the whole process \u201chorribly traumatic.\u201d<\/p>\n
\u201cYou have to navigate the most complicated system on the planet,\u201d she said. \u201cIf you\u2019re just sitting there waiting for them to take care of you, they won\u2019t.\u201d<\/p>\n
A new KFF report found<\/a> that patients who are covered by Medicaid appear to be particularly impacted by prior authorization, regardless of their health concerns. About 1 in 5 adults on Medicaid reported that their insurer had denied or delayed prior approval for a treatment, service, visit, or drug \u2014 double the rate of adults with Medicare.<\/p>\n
\u201cConsumers with prior authorization problems tend to face other insurance problems,\u201d such as trouble finding an in-network provider or reaching the limit on covered services, the report noted. They are also \u201cfar more likely to experience serious health and financial consequences compared to people whose problems did not involve prior authorization.\u201d<\/p>\n
In some cases, patients are pushing back.<\/p>\n
Ron and Teresa Winters at their home in Durant, Oklahoma. Winters blames the Department of Veterans Affairs for setting up roadblocks that have delayed treatment for his bladder cancer.(Desiree Rios for KFF Health News)<\/span><\/figcaption><\/figure>\n
In November, USA Today reported<\/a> that Cigna admitted to making an error when it denied coverage to a 47-year-old Tennessee woman as she prepared to undergo a double-lung transplant to treat lung cancer. In Michigan, a former health insurance executive told ProPublica<\/a> that the company had \u201ccrossed the line\u201d in denying treatment for a man with lymphoma. And Blue Cross and Blue Shield of Louisiana \u201cmet its match\u201d when the company denied a Texas trial lawyer\u2019s cancer treatment, ProPublica reported<\/a> in November.<\/p>\n
Countless others have turned to social media to shame<\/a> their health insurance companies into approving prior authorization requests. Legislation has been introduced in at least 30 states<\/a> \u2014 from California to North Carolina \u2014 to address the problem.<\/p>\n
Back in Oklahoma, Ron Winters is still fighting. According to his wife, Teresa, the surgeon said if Ron could have undergone his operation sooner, they might have avoided removing his bladder.<\/p>\n
In many ways, his story echoes the national VA scandal<\/a> from nearly a decade ago, in which veterans across the country were languishing \u2014 some even dying \u2014 as they waited for care.<\/p>\n
In 2014, for example, CNN reported<\/a> on veteran Thomas Breen, who was kept waiting for months to be seen by a doctor at the VA in Phoenix. He died of stage 4 bladder cancer before the appointment was scheduled.<\/p>\n
Winters\u2019 cancer has spread to his lungs. His diagnosis has advanced to stage 4.<\/p>\n
\u201cReally, nothing has changed,\u201d Teresa Winters said. \u201cThe VA\u2019s processes are still broken.\u201d<\/p>\n
Do you have an experience with prior authorization you\u2019d like to share? <\/em>Click here<\/em><\/a> to tell your story.<\/em><\/p>\n
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