OPINION compared to the copay.“ Patient:“ You can’ t seriously be asking me to take this med.”
Me:“ Never. I’ m just explaining the way their approval process works.”
My philosophy for blood pressure medications was to adhere, when humanly possible, to medicines taken once a day. This required the least effort on the part of the patient: once a day, down the hatch, done. Naturally this failed for some, and they had to gird their loins for remembering extra, morning and night. Some people loved diuretics: they breathed better or weighed less, or both. Some people hated them: muscle cramps and feeling washed-out and limp. Some people loved beta blockers: they took the edge off.“ I don’ t yell in meetings anymore,” they mused. Other people hated them:“ I can’ t even get off the sofa.” Some people loved amlodipine: it was smooth, not sudden. Other people hated it – their ankles swelled. It was always a matter of trial and error.
And all that was before AI entered the marketplace.
Now, the company’ s AI may scan the request and issue an immediate denial for the requested drug, without supplying a formulary alternative. The patient and doctor are stonewalled. Phone calls will be necessary. Time will be wasted on hold. Tempers will rise.
Automated denials increase costs to patients, including the cost of worry, anger and frustration: not one of these is good for one’ s blood pressure. The American Medical Association recently found that 61 % of doctors believe that AI is increasing prior authorization denials. Studies have shown that AI algorithms show racial bias if they are built on datasets from historically underrepresented populations, which has been typical in this country.
California has fought back with the“ Physicians Make Decisions Act” of 2025. This law requires that any denial based on medical necessity must be decided by a“ qualified healthcare provider.” That, however, is a somewhat flexible definition. I have in the past pleaded for an expensive arthritis medicine with a retired pediatric allergist( not exactly my peer, although extremely nice) or a retired podiatrist( truly not my peer, gave in rapidly). I have made my case to OB nurse practitioners( easier – anybody over 40 and they threw up their hands in defeat).
Because of the ubiquity and iniquity of AI-generated denials of coverage, NBC News on July 18th featured a company called Claimable, which helps patients fight back. Claimable( www. getclaimable. com) uses its own AI“ to allow patients to customize their appeal letters with comprehensive assessments of clinical research on a drug or treatment, along with other patients’ appeals history with it.” This costs around $ 40 to the patient, who via Claimable successfully got access to a specialty drug for cancer. Previously, the patient and her doctors“ had repeatedly tried to set up a case review by calling a toll-free number that was never answered by a human being, leaving messages that were not returned, faxing paper documents at the company’ s request, and completing letters of medical necessity: all to no avail.” The Claimable submission got her the needed medicine in 48 hours.
If you can’ t beat‘ em, join‘ em. Good luck out there!
Dr. Barry is an internist and Associate Professor of Medicine( Gratis Faculty) at the University of Louisville School of Medicine, currently retired and mulling her next moves.
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