Abstract
KEY POINTS: Inconsistent responses to the prior approval process for similar patients may lead to inequities in access to optimal care. The prior authorizations process leads to frustration among nephrologists and may contribute to moral distress. The prior authorizations process may lead to important delays in kidney care. BACKGROUND: In Switzerland, nephrologists must frequently obtain preauthorizations from health insurers for certain medications/tests for individual patients. These are time consuming, and outcomes are inconsistent. Clinical experience suggests inequities in access to expensive medications, related to need for and processes involved with medication preauthorization requests. METHODS: An anonymous survey was conducted between November 2021 and March 2022 regarding experiences in applying for preauthorizations for medications and genetic testing required for kidney care among nephrologists in Switzerland. RESULTS: Ninety-four responses were received. The most common medications reported to require preapprovals were rituximab, sodium glucose cotransporter-2 inhibitors (SGLT2is), mycophenolate mofetil, and eculizumab. Rebuttals were reported to be most frequently required for rituximab, eculizumab, and SGLT2is, also the most frequently denied medications. Most frequent genetic testing requests were for complement and Alport spectrum disorders. Requests for genetic testing were reported to be most frequently denied for cystic renal diseases, congenital syndromes, and nephrotic syndromes. Most nephrologists found requests for further information from the health insurers seldom reasonable, 72% reported it was rarely/never possible to engage with the insurance physicians, 69% were concerned insurance physicians did not have relevant expertise. Respondents reported receiving different responses from different insurers for similar requests more frequently than from the same insurer (58% versus 8%). One in three nephrologists reported that the preauthorizations process frequently resulted in a clinically relevant delay in treatment. Four of five respondents reported that the preauthorization process frequently made them feel that they could not do their best for the patient. CONCLUSIONS: From the perspective of nephrologists, the preauthorizations process in Switzerland is cumbersome, is not transparent and inequitable, may result in denial or delays of important treatment for patients, and contributes to moral distress.