Insurers Regularly Delay, Deny, and Defend Their Treatment Malfeasance

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

New research conducted by Johns Hopkins Bloomberg School of Public Health and published in the Journal of the American Medical Association Health Forum found that health insurance denials for brand-name medications increased by 67% between 2018 and 2024, from 24.3% in 2018 to 40.7% in 2024 (Wang et al., 2026). It is yet the latest news showcasing how insurance companies are putting the squeeze on patients.

Photo Source: Johns Hopkins

Wang et al. utilized 2024 IQVIA pharmacy claims data to identify branded drug dispensations that faced initial prior authorization (PA) rejections and completed the PA process, calculating the frequency of same-day PA reviews and final approval rates.

They found that nearly one-third of initial prescription fill attempts (32%) were rejected because of formulary exclusions, including the medication not being covered by the patients’ insurance plan or because of utilization management rules (PA requirements). Of those rejections, nearly half (48.4%) were not followed by a prescription fill of either the prescribed drug or a drug in the same therapeutic class within 90 days. Those patients who were able to successfully appeal their rejections waited an average of 12 days before receiving their prescriptions (Bloomberg School of Public Health, 2026).

These findings highlight a common strategy employed by health insurance companies in the United States: “Delay, Deny, Defend.” This strategy—also the title of a 2010 book about the insurance industry written by Jay Feinman—is implemented by insurers in order to increase profits. Here’s how it works:

Insurers “delay” the processing of claims—particularly PA claims—in order to frustrate policyholders into abandoning their claims. This is accomplished by introducing bureaucratic obstacles, such as requiring numerous forms or claiming that forms were incorrectly filled out or filed, in the hopes that, by increasing the number and length of delays, insured patients will abandon their treatments.

Insurers also “deny” insurance claims, even if services are listed as being covered by a patient’s explanation of benefits. They utilize this tactic knowing that a vanishingly small percentage of patients will appeal those denials. Data published by KFF in March 2026 found that, among marketplace insurance plan holders, fewer than 1% of denied claims were appealed by policyholders. When policyholders do appeal, two-thirds of those appeals are rejected (Long et al., 2026).

If neither the “delay” nor “deny” tactics are successful, insurers may choose to “defend” their decisions in court. These legal battles can be extensive, last for years, and be both financially and emotionally taxing, which insurers rely upon to dissuade patients from fighting back against them (DeShaw, 2024).

Photo Source: Wikipedia

Wang et al.’s research found significant disparities between payors. Marketplace exchange plans and Medicaid managed care plans had the highest rates of denials—the plans most likely to be utilized by patients who have lower incomes or chronic ailments—with nearly half of all initial prescription attempts denied. Meanwhile, Medicare plans had lower rejection rates. Rejection rates may be lower because the vast majority of prescription drug prices are not negotiable under Medicare plans, while price negotiations are legal for commercial and Medicaid plans, meaning higher profits and payouts under Medicare plans.

As with last week’s blog ("Co-Pay Accumulators Are a Craven Attempt to Accumulate Profit Off the Backs of Patients"), this fundamental truth must be recognized and accepted to understand why these tactics are used:

The purpose of commercial health insurance companies is not to provide access to healthcare services; it is to make profits.

So long as the profit motive exists, insurers will work to ensure that they make those profits, even if it means that patients delay or abandon treatment; even if it means that patients die.

These strategies underpin another looming threat:

State programs, including those in Colorado and Connecticut, have recently been moving HIV antiretroviral medications out of protected drug classes that are generally covered under Medicaid medical benefits, and onto prescription drug formularies, creating lists of approved HIV therapies.

Photo Source: WalletInvestor.com

This poses a significant threat to people living with HIV/AIDS, as virtually every medication used to treat HIV is a brand-name drug. By removing HIV treatments as a medical benefit and placing them into a prescription benefit, patients whose HIV can only be managed by specific drug classes due to drug resistance may face the real risks that their prescriptions may be denied not because those drugs are not effective, but because payors wish to reduce prescription drug expenditures and make profits.

ADAP Advocacy vehemently opposes efforts by states and commercial insurers to profit off of patients. We need legislation that ends these practices. Whether politicians have the political will to enact such policies has yet to be seen.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] Bloomberg School of Public Health. (2026, July 10). Insurance Denials for Brand-Name Prescription Drugs Rose Sharply From 2018 to 2024. Baltimore, MD: Johns Hopkins University: Bloomberg School of Public Health. https://publichealth.jhu.edu/2026/insurance-denials-for-brand-name-prescription-drugs-rose-sharply-from-2018-to-2024

[2] DeShaw, A. (2024, December 11). What Does “Delay, Deny, Defend” Mean? Portland, OR: DeShaw Law: Blog. https://www.deshawlaw.com/blog/what-does-delay-deny-defend-mean

[3] Long, M., Lo, J., & Pestaina, K. (2026, March 24). Claims Denials and Appeals in ACA Marketplace Plans in 2024. San Francisco, CA: KFF: Topics: Patient and Consumer Protections. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/

[4] Wang, Y., Levy, J. F., Mattingly, T. J., II, & Anderson, G. (2026, April 17). JAMA Health Forum, 7(4), e260760. https://doi.org/10.1001/jamahealthforum.2026.0760

Infusion Clinics Could Expand Utilization of Long-Acting Injectables, but Barriers Hinder Access

By: Ranier Simons, ADAP Blog Guest Contributor

The advent of long-acting injectables (LAI) for HIV prevention and treatment is a noteworthy breakthrough in medical science. Despite the growing number of options and continuing clinical studies showcasing their efficacy, they are under-utilized. While there are various drug-level and patient-level barriers to LAI uptake, one of the most significant barriers is access at the system level (Cooper et al., 2022). Many people who would greatly benefit from LAIs for prevention and people living with HIV/AIDS (PLWHA) in need of better options for treatment can’t access them. Logistics and coverage issues stand as obstacles to life-saving treatment and public health prevention.

Photo Source: HIV.gov

Discrepancies in insurance coverage constitute a significant barrier. In the U.S., 40 percent of PLWHA are insured by Medicaid, and 27 percent get medication from state AIDS Drug Assistance Programs (ADAP) (Zalla et al., 2025). A recent study examined prescription drug formulary coverage of long-acting cabotegravir/rilpivirine (CAB/RPV-LA) for HIV treatment for those who achieved viral suppression and lenacapivir (LEN) for adults with multi-drug-resistant strains. CAB/RPV-LA was not covered without prior authorization (PA) by 26 state Medicaid programs and had no coverage by 15 state ADAPs. LEN was not covered without prior authorization by 32 Medicaid programs and had no coverage by 18 ADAPs (Zalla et al., 2025). Eighteen state Medicaid plans had unencumbered uniform coverage of CAB/RPV-LA with no PA, and 11 had unencumbered uniform coverage of LEN with no PA (Zalla et al., 2025). A distinction is made between coverage with and without PA because prior authorizations for LAIs are particularly cumbersome. Additionally, many health insurers require reapproval processes for continued treatment.

Another recent study surveyed providers inquiring about identified barriers to LAI utilization for treatment and prevention regarding long-acting cabotegravir/rilpivirine (CAB/RPV-LA) for treatment and long-acting cabotegravir (CAB-LA) for HIV prevention (Marcus et al., 2025). These providers highlighted PA approval and appeals, re-verification of eligibility for continuous coverage, and coverage of LAIs as a medical benefit instead of a pharmacy benefit (Marcus et al., 2025).

Both studies highlight the central barrier of insurance bureaucracy as a hindrance to LAI access. Cumbersome PAs delay the initiation of treatment. Requiring re-verification of eligibility for treatment not only causes treatment delays but also adds to the administrative burden of providers (Marcus et al., 2025; Zalla et al., 2025). Providers cannot afford to be saddled with the extra administrative burden of soliciting and managing PAs or the financial expenditure of hiring staff for that purpose. Additionally, when LAIs are covered under insurance as a medical benefit instead of a pharmacy benefit, that can require a provider to purchase medications on the front end and bill the insurance on the back end in a “buy and bill” situation (Marcus et al., 2025). Not only is a financial investment for the medications required, but special storage and refrigeration is required. This may be logistically challenging and cost-prohibitive to a provider.

Photo Source: Pharmacy Practice News

When vulnerable patients rely on Medicaid or ADAPs to obtain LAIs, poor formulary coverage means a lack of access. Even if there is coverage, patients fall in and out of eligibility for Medicaid and ADAPs regularly due to income restrictions. When there is non-alignment of coverage between Medicaid and ADAP in a state, patients risk lengthy treatment interruptions. This is dangerous because LAIs remain in the body for long periods of time at low levels. As such, treatment interruptions can result in developing drug resistance (Zalla et al., 2025).

One solution to assist providers in avoiding some of the challenges of administering LAIs is referral to infusion clinics. Increasing the utilization of infusion clinics to administer LAIs would be an innovation of care delivery and implementation science from a process improvement perspective. As founder and CEO of Agile Infusion Services LLC, Yossi Faber states, “Freestanding ambulatory infusion clinics play a crucial role in expanding access to long-acting injectables for HIV prevention and treatment. However, without addressing systemic barriers such as restrictive insurance policies, provider education gaps, and operational constraints, these therapies won’t reach those who need them the most. Ensuring sustainable policies and adequate provider support is key to equitable access.”

Infusion centers that are not inside hospitals or other medical practices solely focus on infusion and injection therapies. Freestanding centers are in communities; thus, they are often more convenient for patients in terms of physical access. Additionally, the centers’ staff are highly trained with respect to injections and infusions. The advanced training increases patient safety and is a standard operational characteristic of their care model. They have lower overhead and can negotiate with payers at a lower price (Cheney, 2022).

Photo Source: Rx Toolkit

Primary care doctor offices and other medical clinics do not typically have the built-in workflow, refrigeration, and storage capacity, nor administrative capacity to effectively handle the utilization of LAIs. Infusion centers are experienced with the administrative navigation of prior approvals, medication handling, medication dispensing, and the logistics of obtaining drugs from specialty pharmacies. Moreover, primary care doctors are not well-versed on preventative LAIs. PLWHA utilize providers experienced with LAIs for their care. Those desiring LAIs for PrEP are typically unfamiliar with the HIV treatment landscape and have an unclear path to access. Faber explains, “This lack of awareness on the part of providers can result in significant underutilization of these therapies, as providers are often hesitant to recommend treatments with unfamiliar medications or modalities, particularly if they are unaware of where such therapies can be obtained.” Referring patients to infusion centers to administer LAIs for treatment and prevention is part of a comprehensive solution.

There is a dire need to improve access to long-acting injectable medications. Patients need to access many other beneficial therapies, such as Trogarzo, an LAI for treatment-resistant HIV, and Abilify Maintena for antipsychosis. Solutions to access issues require a multi-faceted approach. Policy intervention is necessary for insurers to streamline the PA process and remove the need for LAI reapproval. Congress should pass PrEP legislation to bolster assistance to people who are uninsured or underinsured. States should fund PrEP assistance programs. Congress should also increase funding for the Ryan White HIV/AIDS Program to help with the evolving demand for LAIs for treatment and prevention to make sure those vulnerable populations who can benefit the most are empowered with access. Medical science is evolving quickly. Thus, policy and funding innovation must also evolve to ensure equitable access to effective treatment for all.

[1] Cheney, C. (2022, August 3).Standalone Infusion Center CEO: 'The Patient Experience Is Superior.' Retrieved fromhttps://www.healthleadersmedia.com/clinical-care/standalone-infusion-center-ceo-patient-experience-superior#:~:text=Standalone%20infusion%20centers%20can%20offer,with%20lower%20overhead%20and%20expenses.

[2] Cooper, S. E., Rosenblatt, J., & Gulick, R. M. (2022). Barriers to Uptake of Long-Acting Antiretroviral Products for Treatment and Prevention of Human Immunodeficiency Virus (HIV) in High-Income Countries. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 75(Suppl 4), S541–S548. https://doi.org/10.1093/cid/ciac716

[3] Lauren C Zalla, Tim Horn, Sita Lujintanon, Catherine R Lesko, State-Level Variation in Access to Long-Acting Injectable Antiretroviral Therapy for HIV in the United States, Health Affairs Scholar, 2025;, qxaf016, https://doi.org/10.1093/haschl/qxaf016

[4] Marcus, J. L., Weddle, A., Kelley, C. F., Agwu, A., Montalvo, S., Sherman, E., Vijayan, T., Gutierrez, J., Hickey, M. D., Dilworth, S. E., Krakower, D., Davis, T. L., Collins, L. F., McNulty, M. C., Colasanti, J. A., & Christopoulos, K. A. (2025). Policy recommendations to support Equitable access to Long-Acting Injectables for Human Immunodeficiency virus prevention and Treatment: A policy paper of the Infectious Diseases Society of America and the HIV Medicine Association. Clinical Infectious Diseases. https://doi.org/10.1093/cid/ciae648

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

Prior Authorization: A Growing Headache for Patients

By: Ranier Simons, ADAP Blog Guest Contributor

Amidst all the complicated machinations of the U.S. healthcare system, the ultimate focus should be the patient's best interests. Unfortunately, many barriers interfere with physicians and patients working together for the most optimal outcomes. One of those pervasive barriers is prior authorization. Prior authorization (PA) is when insurers require healthcare providers to obtain pre-approval for things such as services, procedures, durable medical goods, and medications. The pre-approval is required before insurance companies will agree to pay for a requested intervention. Insurance industry messaging claims that prior approvals are in the best interests of patients to make sure that inappropriate care is not needlessly utilized, thus saving them money, lowering healthcare system expenditures, and ensuring only the most effective options for care are chosen by physicians. 

Photo Source: Salon (Getty Images/FG Trade)

However, PAs are not in patients' best interests but are a method of cost control or cost-cutting to save insurers money. Jen Laws, CEO of Community Access National Network, states, “Taking a note from auto carriers, payers have been utilizing prior authorization as a bet that most folks don't have time, energy, or navigation experience enough to fight for the care patients rightly need. It's delay and deny on the bet that patients will give up." PAs have detrimental effects on patient health outcomes, interfere with the patient-physician relationship, unduly burden physicians, and ultimately generate more healthcare spending, because of medical interventions needed because of the poor patient outcomes they can cause.

For several years, many groups have been fighting for prior authorization reform. Recently, in a step in the right direction, the Centers for Medicare and Medicaid Services (CMS) released their Final Prior Authorization and Interoperability Rule (CMS-0057-F).[9] Even though it is a win for patients and providers, it is not enough. As such, legislatures nationwide are working on state-level legislative remedies to the prior authorization problem. Some states have already passed more stringent measures, and others have bills in process.[6]

The new rule has many details, but there are some notable highlights. A significant problem with the prior authorization process is the excessive time burden placed on medical providers.[1] According to a 2022 American Medical Association (AMA) survey, physicians and their staff spend an average of about 14 hours, roughly two business days per week, completing around 45 PAs per physician.[7] Historically, much of the PA process is manual, requiring long phone calls and forms to be filled out, faxed, or sent through postal mail. The CMS rule helps with this by requiring insurers to support an electronic prior authorization process that is embedded in the physician’s electronic health records. This streamlines the process and helps with automation since the electronic health record is a centralized place where physicians do much of their work. Patients regularly see their physician typing things like notes and prescription requests in the examination room during their visits.

Photo Source: American Medical Association

Another remedy the new CMS rule delivers is transparency. When PAs are often denied, physicians and patients don’t know why since the insurers don’t give clear reasoning. They respond with opaque responses such as deeming a requested medical intervention as ‘medically unnecessary’. The new rule requires insurers to give very specific reasons for denial. This will not only enable providers to refute and appeal denials more effectively but can result in more accountability of insurers. Having to provide precise reasoning will result in insurers being more cautious with denials. CMS furthers transparency requirements by requiring metrics reporting. The new rule requires insurers to publicly report their actions such as how often they approve and deny PAs, how long they take to make decisions, as well as the frequency of denials and approvals by medical ailment category. This will enable patients to be informed consumers as they shop for insurance coverage. 

The new CMS rule has many positive details but also limitations. The ruling does not pertain to prescription drugs. The ruling also only applies to government-regulated health plans such as Medicaid, CHIP, Medicaid managed care plans, and plans on the healthcare exchange. The electronic PA requirement goes into effect in 2027, and the metric reporting goes into effect in 2026. To create more substantial changes, some states have already passed PA reform legislation, and many others are working on it. The District of Columbia has already passed legislation with some of the same aspects as the CMS ruling, but also goes further.

The District of Columbia passed Bill 25-124, which became ACT 25-301 in November 2023.[5] The act has an electronic PA requirement in the same manner as the CMS rule. It requires all review entities to accept and respond to PA requests using their NCPDP SCRIPT Standard ePA transaction by January 1, 2024.[5] The D.C. Act goes beyond the CMS ruling regarding required timeframes for PA decisions. The CMS ruling requires review entities to respond within 72 hours for expedited urgent care PA requests and within seven days for standard requests. The D.C. Act requires review entities to respond within 24 hours with approval or denial of urgent care PA requests.[5] For standard requests, it specifies a response within three business days by electronic portal or five business days by mail, fax, or telephone.[5]

North Carolina is one of the states with pending PA legislation. Its details also contain some requirements that are more stringent than those of CMS. Like the D.C. Act, one highlight is its timetable for review response specification. For non-urgent healthcare services PA requests, an insurer must decide within 48 hours of obtaining all required information and within 24 hours for urgent care requests.[10] The North Carolina bill also contains transparency language. Suppose the reviewing entity of an insurer questions the medical necessity of a physician’s PA request. In that case, it must notify the provider within five business days of the date of the request.[10] Also, before issuing a PA denial, the insurer must allow the affected provider to discuss the need for the medical service on the telephone directly with the medical doctor who will be responsible for the review determination.[10]

Photo Source: American Medical Association

Current and developing state legislation model suggestions supported by the AMA. One of those is “gold carding”. Five states have already passed gold carding legislation: Louisiana, Michigan, Texas, Vermont, and West Virginia.[6] In gold carding, six months of a medical practice or provider’s prior authorizations are reviewed. If 90% of the requests are approved, then that practice or provider is not subject to any PA requirements for six months.[6,8] Maintaining those statistics would be required to maintain the privilege. While on the surface, it seems to be a good way to reduce the volume of PAs, thus reducing administrative time waste, it has a downside. As Jen Laws points out, “Gold carding can come with the incentive for payors to become even more aggressive in their PA and other UM (utilization management) practices because it rests on the idea that a provider can "prove" they don't need review. The best way around that is to merely get more aggressive with UM, moving the goalpost to an unattainable standard.”

The adverse effects of prior authorizations are well documented. They cause physician burnout, interfere with the patient-provider relationship, and cause delays in patient care.[3,7] Delays in patient care can result in avoidable poor patient health outcomes and exacerbation of disease states.[2,3,4] In diseases such as cancer, timely and very personalized treatment can be a matter of life and death. Physicians make very informed decisions about their patients’ medical care. When physicians make evidence-based treatment determinations for their patient's best health, they should not be undermined by profit-centric cost-cutting measures that are not based on proper consideration of current medical data. Pushing forward to ensure transparency and accountability is critical. It will take continued federal and state efforts to create a healthcare landscape that genuinely has the patient at its center.

[1] Medical Ecconomics. (2023, August 4). 2023 Physician Report: The latest physician salary, productivity and malpractice cost data. Retrieved from https://www.medicaleconomics.com/view/2023-physician-report-the-latest-physician-salary-productivity-and-malpractice-cost-data?slide=18

[2] Sausser, L. (2023, December 2023). Cancer patients face frightening delays in treatment approvals. Retrieved from https://kffhealthnews.org/news/article/cancer-patients-prior-authorization-treatment-delays/

[3] Merrill, J. R., Flitcroft, M. A., Miller, T., Beichner, B., Clarke, C. N., Maduekwe, U. N., Wang, T. S., Dream, S., Christians, K. K., Gamblin, T. C., Evans, D. B., & Kothari, A. N. (2023). Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice. The Journal of surgical research, 288, 269–274. https://doi.org/10.1016/j.jss.2023.03.013

[4] Miller, T. (2023, November 7). Big insurance met its match when it turned down a top trial lawyer's request for cancer treatment. Retrieved from https://www.propublica.org/article/blue-cross-proton-therapy-cancer-lawyer-denial#:~:text=Blue%20Cross%20and%20Blue%20Shield%20denied%20payment%20for%20the%20proton,he%20was%20ready%20to%20fight.

[5] Council of the District of Columbia. (2023, November 15). D.C. ACT 25-301 Prior Authorization Reform Amendment Act. Retrieved from https://lims.dccouncil.gov/downloads/LIMS/52301/Signed_Act/B25-0124-Signed_Act.pdf?Id=180462

[6] Sable-Smith, B. (2024, February 12). States target health insurers' 'prior authorization' red tape. Retrieved from https://kffhealthnews.org/news/article/states-health-insurers-prior-authorization-legislation-gold-carding/

[7] American Medical Association. (2023). 2022 AMA prior authorization (PA) physician survey. Retrieved from https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

[8] American Medical Association. (2024, January 24). Advocacy in action: Fixing prior authorization. Retrieved from  https://www.ama-assn.org/practice-management/prior-authorization/advocacy-action-fixing-prior-authorization

[9] Centers for Medicare and Medicaid Services. (2024, January 17). CMS Finalizes rule to expand access to health information and improve the prior authorization process. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

[10] North Carolina General Assembly. House Bill 649 - Ensure Timely/Clinically Sound Utiliz. Review. Retrieved from https://www.ncleg.gov/Sessions/2023/Bills/House/PDF/H649v0.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

Prior Authorization: Friend or Foe?

By: Ranier Simons, ADAP Blog Guest Contributor

It is no secret that the United States has the highest healthcare expenditures in the world but does not have the healthcare outcomes to reflect the spending. Rampant healthcare expenditures financially burden individuals, health care systems, governments, and private industry. Discourse surrounding healthcare spending reform juggles questions of the pricing of pharmaceuticals and durable medical equipment, the fees paid for medical services and facilities, administrative fees, and even decisions of medical intervention based on perceived necessity. The Institute for Healthcare Improvement created a framework called the Tripe Aim: improve the health of the population, enhance the experience and outcomes of the patient, and reduce per person cost of care.[1] Unfortunately, many standard healthcare cost-benefit analyses do not benefit patients. They benefit profit. One such practice is Prior Authorization, also known as PA.

Photo Source: ViAANTE

PA is part of what insurance companies and other medical payers refer to as utilization management. Simply put, when a medical professional orders a procedure, modality, or medication, it is not automatically paid for by a patient’s insurance. Depending on the structure of the health plan, approval is required before an action is taken to guarantee it is covered by the insurance. If prior authorization is not obtained the patient and/or healthcare practice could face being required to pay full price out of pocket or healthcare providers not receiving reimbursement. Additionally, if a prior authorization is denied, that means the health plan will not pay and the patient is still faced with the question of paying full fees or forgoing prescribed treatment. 

In theory, Prior Authorization is supposed to lower health care expenditures by preventing waste. Waste in this case is defined as high utilization of expensive procedures, appliances, or medications in lieu of lower cost alternatives. Unfortunately, the current way PA operates can harm the patient, in favor of profit. 

A medical provider and patient together work on a treatment plan and decide on medications. The provider makes prescriptions based on what they feel is best for the health outcomes of the patient. When health plans deny Prior Authorizations, they often suggest alternative solutions based on cost that may not be as effective or effective at all. These plans use panels of professionals that include physicians and nurses to review and authorize/deny providers requests. Faced with a denial, a provider has to fight get the desired treatment approved.[2] Documentation has to be submitted providing rationale for desired treatment and why alternative treatment will not be as effective. Sometimes providers have to petition to show treatment is even necessary when PA denial is denial of any medical treatment at all.

Photo Source: MedPage Today

Prior authorization sometimes results in delays in care that can result in adverse health outcomes, hospitalizations, permanent bodily damage, or even death.[2] To address this issues New York state has something called prescriber prevails, which is prior authorization process that applies to Medicaid plans. Under prescriber prevails, for a select group of drugs, the process is an expedited three business days from request process where providers have the final say in approval instead of a third-party panel provided by a health plan.[3] The drug classes covered by prescriber prevails includes anti-depressants, anti-psychotics, anti-rejections, seizure and epilepsy, endocrine, hematologic, and immunologic.[4] This means that doctors have the final say for things like anti-viral medications for HIV. Unfortunately, it does not cover antiviral drugs for hepatitis C.[4]

Lowering health care expenditures should lower the financial burden of healthcare primarily for patients and medical providers. When lowering the costs of health plans results in poor patient outcomes, expenditures actually increase with resulting patient hospitalizations, treatment abandonment, and resulting later stage acute treatment utilization. Groups pushing for healthcare reform advocate for prescriber prevails policy to be expanded to other drug classes covered by Medicaid nationally, as well as forms of prescriber prevails for non-Medicaid health plans. Efforts to reform healthcare need to be patient-focused not profit-focused.

[1] Institute for Healthcare Improvement. (2022). Triple aim for populations. Retrieved from https://www.ihi.org/Topics/TripleAim/Pages/default.aspx
[2] Laws, J. (2022, Apr 4). Provider survey: Prior authorizations harm patients. Retrieved from https://www.hiv-hcv-watch.com/blog/4-4-2022
[3] Health Plan Association. (2019, Mar 4). Memorandum in opposition. Retrieved from https://nyhpa.org/2019/03/s-1794-a-a-2799-a-medicaid-prescriber-prevails/
[4] Hep Free NYC. (2016, Mar 16). Policy Brief: Prescriber prevails & Hep C in NYS. Retrieved from https://hepfree.nyc/policy-fact-sheet-prescriber-prevails-hep-c/

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.    

HIV/AIDS Fireside Chat Retreat in Wilmington, NC Tackles Pressing Issues

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The ADAP Advocacy Association hosted an HIV/AIDS "Fireside Chat" retreat in Wilmington, North Carolina among key stakeholder groups to discuss pertinent issues facing people living with HIV/AIDS. It was the first Fireside Chat in over two and a half years, after they were suspended in response to the ongoing Covid-19 pandemic. The Fireside Chat took place on Thursday, June 16th, and Friday, June 17th. Utilization Management, Ending the HIV/AIDS Epidemic (in the South), and Covid-19's Impact on Public Health were evaluated and discussed by 22 diverse leaders in the fight against the HIV/AIDS epidemic.

Photo Source: Getty Images

The Fireside Chat included moderated white-board style discussion sessions on the following issues:

• Utilization Management: What is its Impact on Patient Access to Care and Treatment — moderated by Murray Penner, U.S. Executive Director, Prevention Access Campaign (PAC)
• Ending the Epidemic (EHE): What is its Impact in the South — moderated by Lee Storrow, National Policy Director, Community Education Group (CEG) & Board Chair, Southern AIDS Coalition (SAC)
• Covid-19: What is its Impact on HIV, Viral Hepatitis, Sexually Transmitted Infections (STIs), and Substance Use Disorder — moderated by Jen Laws, President & CEO, Community Access National Network (CANN) & Board Member, ADAP Advocacy Association

The discussion sessions were designed to capture key observations, suggestions, and thoughts about how best to address the challenges being discussed at the Fireside Chat. The following represents the attendees:

• Guy Anthony, Founder, Black, Gifted & Whole
• De' Shea Coney, HepConnect Coordinator, North Carolina AIDS Action Network
• Tori Cooper, Director of Community Engagement, Human Rights Campaign
• Dawn Patillo Exum, Director of Public Policy, Merck
• Jasmine Ford, HIV Clinical Coordinator, Virginia Department of Health
• Dusty Garner, Board Member, Community Access National Network
• Aquarius D. Gilmer, Associate Director, Corporate Policy & Alliances, Gilead Sciences
• Marcus J. Hopkins, Founder & Executive Director, Appalachian Learning Initiative
• Tim Horn, Director, Health Care Access, National Alliance of State & Territorial AIDS Directors (NASTAD)
• Venton Jones, Chief Executive Officer, Southern Black Policy & Advocacy Network
• Jen Laws, President & CEO, Community Access National Network
• Brandon M. Macsata, CEO, ADAP Advocacy Association
• Judith Montenegro, Program Director, Latino Commission on AIDS
• Murray Penner, Executive Director, North America, Prevention Access Campaign
• Kalvin Pugh, Sr. Manager, Community Engagement at International Association of Providers of AIDS Care
• Alan Richardson, Executive Vice President of Strategic Patient Solutions, Patient Advocate Foundation
• Carl Schmid, Executive Director at HIV + Hepatitis Policy Institute
• Robert Skinner, Advocate — Florida
• Cindy Snyder, Director, Government Relations, ViiV Healthcare
• Lee Storrow, National Policy Director, Community Education Group
• LaWanda Wilkersaon, Advocate — North Carolina
• Joey Wynn, Chairman, Florida HIV/AIDS Advocacy Network (FHAAN)

The Covid-19 pandemic is still ongoing, and accordingly to The New York Times (as of June 14th), “The average number of new cases in the United States fell to 98,867 yesterday, a 2 percent decrease from the day before. Since January 2020, at least 1 in 4 people who live in the United States have been infected, and at least 1 in 330 people have died” (NYT, 2022).

With that in mind, the ADAP Advocacy Association implemented strong Covid-19 safety protocols for the Fireside Chat, which included proof of vaccination/booster, robust self-administered testing (prior to travel, upon arrival, and after returning home), complimentary rapid self-test kits and hand sanitizer for each of the attendees, as well as guidelines for masks on commercial travel to the event, and optional masks during the sessions (which some attendees exercised without feeling shunned). 

At the meeting's outset, a signature fishing vest with its AIDS red ribbon owned by the late Bill Arnold, longtime President & CEO of the Community Access National Network (CANN), was gently placed on one of the chairs in the room. It was meant to symbolize that Bill would always have a seat at the table in an honorary way to pay tribute to the decades of advocacy work done on behalf of people living with HIV/AIDS dating back to the 1980s. There wasn't a dry eye in the room!

Bill Arnold, August 13, 1938 - September 29, 2021

The ADAP Advocacy Association is pleased to share the following brief recap of the Fireside Chat.

Utilization Management (UM):

Murray Penner provided a basic overview on the managed care practice, often referred to as utilization management (or utilization review), used by payers of health services, such as commercial insurance plans, public health programs (i.e., Medicaid, Medicare, Ryan White), Veterans Affairs, and other programs. Today, patients need to be savvy, because the United States has one of the most expensive and fragmented healthcare delivery systems in the world. UM can indeed serve a purpose, but the reality is that purpose if often clouded by the pitfalls.

According to Penner: "UM is a process that payers and healthcare plans utilize to evaluate the medical necessity, appropriateness, and efficiency of the use of health care services (medicines, procedures, etc.). There are valid reasons for UM (particularly medical necessity), but UM is also often used to help contain costs and to deny coverage of high cost meds and procedures in favor of lower cost alternatives. With HIV medications, in particular, it often restricts access to medications that providers and patients have determined as necessary for appropriate care and treatment. UM practices in theory are appropriate for safety and continuity of care, but far too often they have become discriminatory and present challenges to accessing medications and remaining adherent to them."

Penner's discussion on UM started with a broad overview of the practice, including examples, clinical efficacy, and provider feedback. It also included the impacts of UM on patient access, Ending the Epidemic efforts, and viral suppression, as well as the statutory and regulatory protections and limitations. 

Prior authorization is probably the most commonly-known technique exercised by payers, but many others exist. An important part of the conversation centered around a recent survey on prior authorization released by the American Medical Association (AMA), 2021 AMA prior authorization (PA) physician survey.  

The survey found, sadly, that one in four patients often abandon their recommended course of treatment, and a staggering "82% report that PA can at least sometimes lead to treatment abandonment." The survey focused on patient impact, but it also featured relevant information on physician impact and employer impact. The survey results can be found online at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf.

Photo Source: American Medical Association

Patients needing to complete eligibly "recertification" under the State AIDS Drug Assistance Program (ADAP) was also a hot topic of conversation. Most States require the bureaucratic red tape be rolled-out every six months, which is widely accepted as unnecessary. Fortunately, some flexibility was recently authorized by the Health Resources & Services Administration (HRSA) on the ADAP recertification process. The Virginia Department of Health, for example, is extending their program recertification to every 24 months!!!

Other UM-related issues discussed included drug formularies, convoluted Rx refill cycles, safety protections afforded to patients (i.e., drug contraindications), and the "prescriber prevails" provisions under New York Medicaid.

The following materials (partial list) were shared with retreat attendees:

• American Medical Association - 2021 AMA prior authorization (PA) physician survey. American Medical Association
• American Medical Association - Prior Authorization and Utilization
• Centers for Medicare and Medicaid - CCIIO Regulations and Guidance
• Harvard Health Publishing - Do generic drugs compromise on quality? 
• Health Affairs - Quantifying The Economic Burden Of Drug Utilization Management On Payers, Manufacturers, Physicians, And Patients
• Journal of Managed Care & Specialty Pharmacy - The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review
• AIDS and Behavior - The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations 
• NBC News - Transgender people report years of battles for health insurance coverage 

The ADAP Advocacy Association would like to publicly acknowledge and thank Murray for facilitating this important discussion.

Ending the HIV Epidemic (in the South):

The Ending the HIV Epidemic (EHE) in the United States initiative has been front and center among HIV advocacy circles since it was announced during a previous president's State of the Union. According to the U.S. Centers for Disease Control & Prevention (CDC), "The EHE initiative is scaling up four science-based strategies that can end the epidemic: Diagnose, Treat, Prevent, and Respond. For maximum impact, CDC is continuing to invest in communities most affected by HIV — to help local HIV programs recover, rebuild, and begin to expand EHE strategies in the wake of COVID-19."

Lee Storrow summarized it more clearly as, "Refocusing limited resources to target the hot spots." Despite the EHE initiative being characterized by some advocates as off to a middling start, it does still represent the first new influx of significant federal dollars in quite some time. Of particular importance to this discussion was EHE's footprint in the South (and Appalachia), which is disproportionately impacted by HIV/AIDS.

Of course, one of the biggest - and still ongoing - topics of intense conversation center around why some apparent hot spots are included under the EHE initiative, while others were excluded. For example, West Virginia. Neither West Virginia nor any of its 55 counties were included as Phase 1 jurisdictions of the EHE initiative. Considering the state has two enduring, intertwined epidemics, West Virginia's exclusion highlighted some of the initiative's shortcomings.

According to Storrow: "The participants of the fireside chat had a wealth of big ideas about how we could make a big impact when it comes to HIV rates in the South and Appalachia. Ending the Epidemic isn’t just a reference to the plan and funding source, it’s a mindset to catalyze new energy and bring new resources to bare to combat HIV. When I was working in HIV advocacy in North Carolina, we took advantage of the moment in time the announcement of the federal EHE created to get new state funding from the NC General Assembly. We’ve got to leave it all on the line and leave no stone unturned to make sure the HIV advocacy community has the resources and tools to get this work done."

Storrow's discussion on EHE (in the South) included a history of the initiative, as well as where we are today fighting the epidemic in the South and in Appalachia. Discussions centered around targets (and whether they'll be met), disruptions caused by Covid-19, state-level EHE plans, and future federal EHE expansion to include other jurisdictions.

Photo Source: ADAP Advocacy Association

Storrow also used the session to raise awareness about the Opioid Settlement Plans that are currently unfolding nationwide. It led to a lively conversation about how those settlement dollars could be leveraged to boost public health programs that specifically impact HIV, viral hepatitis, sexually-transmitted infections, and substance use disorder programs.

Other EHE-related issues discussed included social determinants of health, and ongoing challenges to achieve better health equity.

The following materials were shared with retreat attendees:

• The Hill - Pandemic disrupted HIV prevention efforts, CDC report says
• NPR - Lessons From HIV On Ending The COVID Pandemic
• Office of the Honorable Shelley Moore Capito - CAPITO URGES HHS SECRETARY TO INCLUDE WEST VIRGINIA IN INITIATIVE TACKLING HIV EPIDEMIC; WV initially excluded from federal program aimed at helping communities most affected by HIV
• North Carolina Health News - Mecklenburg among top focus locations in Trump HIV plan
• North Carolina Health News - Zero new HIV cases: the goal for Mecklenburg County
• North Carolina Department of Health and Human Services - NCDHHS Urges Testing During National HIV Testing Day, Releases End the HIV Epidemic Plan
• North Carolina Department of Health and Human Services - NC ENDING THE EPIDEMIC: A Plan to End HIV Together Community-by-Community Hand-in-Hand
• Opioid Settlement Tracker - STATES' OPIOID SETTLEMENT ALLOCATION PLANS

The ADAP Advocacy Association would like to publicly acknowledge and thank Lee for facilitating this important discussion.

Editor's Note: In May 2014, the ADAP Advocacy Association published an issue brief, "THE SOUTHERN EPIDEMIC: Are the South's cultural, political and societal barriers making it difficult for public health programs, such as the AIDS Drug Assistance Programs, to function effectively in this region?" Ironically, many of the topics raised during the EHE (in the South) session were raised nearly ten years ago in our issue brief. The issue brief can be downloaded here.

Covid-19's Impact on Public Health:

In early 2021, Jen Laws penned a blog evaluating the mess being caused by the Covid-19 pandemic. At that time, Laws argued, "Covid-19 has also clearly highlighted the impact of social determinants of health and health disparities of which HIV and HCV [Hepatitis C] advocates have long been aware." He was right, and unfortunately not much as changed 18 months later.

According to Laws: "Public health has taken on new, both exciting and unfortunate, shapes as a result of our collective responses to Covid-19. The expanded use of telemedicine has helped modernize our access to care while also leaving those in more rural areas and impoverished communities of the country at distinct disadvantage due to lack of infrastructure, threatening to widen already existing health disparities. Defining a still shifting landscape as Covid-19 related flexibilities and legal changes, presents numerous challenges to public health as an industry and public health professionals will be digesting these changes and challenges for years, if not decades, to come. This is as true, if not more true, for pre-Covid-19 public health programs focused on infectious disease, including STIs, HIV, and viral hepatitis, as these infrastructures and personnel continue to face uncertain futures in politically hostile environments."

Laws' discussion on Covid-19 impact included background context on the state of public health programs pre-Covid-19, as well as related changes to public health and public health programs. It included discussion on the current and future state of the public health programs important to the HIV community. Some of the key questions asked included: What changes do we want to keep? What changes do we need to do away with? How do we evaluate the paradigm shift in publics' mood toward public health (i.e., anti-science, anti-vaccination)?

Photo Source: CDC

The stated goal of the session was "to define the impacts of COVID-19 on public health infrastructure and programs." It celebrated flexibility and innovation offered by various temporary governmental regulation and the “forced modernization” of health care in many situations – namely, telehealth. Of dire concern, however, are these flexibilities are threatened to end as the public health emergency winds down, including the continuous coverage requirement for Medicaid programs under the public health emergency declaration. Some attendees also stressed that there are downsides to relying on telehealth, especially for rural communities lacking the necessary infrastructure to make health care accessible.

CDC's own HIV surveillance data proves earlier Covid-19 concerns, which was regularly noted.

The following materials (partial list) were shared with retreat attendees: 

• Community Access National Network - Community Roundtable Emphasizes Impacts of COVID-19 (2021) 
• Community Access National Network - Community Roundtable Defines the Shape of Public Health Advocacy Amid COVID-19 (2022) 
• Centers for Disease Control and Prevention - Impact of COVID-19 on STDs. Sexually Transmitted Disease Surveillance 2020
• National Association of County and City Health Officials - NACCHO Requests Protection of Public Health department Officials and Staff from Harassment, Intimidation, and Threats of Violence
• NBC News - Because of Covid, 2020 was a ‘lost year’ in the fight against HIV, report suggests
• Kaiser Health News - Strides Against HIV/AIDS Falter, especially in the South as Nation Battles COVID
• Kaiser Family Foundation - Delivering HIV Care and Prevention in the COVID Era: A National Survey of Ryan White Providers

The ADAP Advocacy Association would like to publicly acknowledge and thank Jen for facilitating this important discussion.

Additional Fireside Chats are planned in September 2022 (Chicago, Illinois).

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.