Marine Corps veteran Ron Winters vividly remembers his doctor's grim evaluation of his bladder cancer diagnosis in August 2022.
"This is a serious situation," the 66-year-old resident of Durant, Oklahoma, recalled his urologist saying. Winters prepared himself for the battle ahead.
However, he never anticipated that his fight would extend beyond cancer. He found himself also facing obstacles from the Department of Veterans Affairs, which Winters holds responsible for the delays in his treatment.
Winters opted not to receive cancer treatment at a VA facility, instead seeking care from a specialist through the Veterans Health Administration's Community Care Program. The program was established in 2018 to provide veterans with more options and reduce wait times. However, Winters described the prior authorization process as a prolonged nightmare.
"It's absolutely ridiculous for them to take weeks, sometimes even months, to provide authorization," Winters expressed. "Whether it's cancer or not, it shouldn't be this way."
John Winters, a patient at the University of Texas Southwestern Medical Center in Dallas, experienced significant delays in receiving necessary medical care through the VA. After his initial diagnosis, he had to wait four weeks for the VA to approve a procedure to remove some of his cancer. Additionally, he had to wait another month for the VA to consider approving surgery to remove his bladder after finishing chemotherapy. Even routine imaging scans required preapproval.
VA press secretary Terrence Hayes acknowledged the unacceptable delay in care and stated that the VA is working with Winters to authorize his ongoing care. Hayes also promised to urgently review the matter and take steps to prevent future delays.
While prior authorization is not unique to the VA, it is a common requirement in both private and federal health insurance programs. The purpose of prior authorization is to reduce spending and avoid unnecessary or ineffective care. However, critics argue that it can be used by insurers to restrict or delay expensive treatments, which can be particularly concerning for individuals with cancer.
Source: KFF Health News
"Prior Authorization: A Roadblock for Cancer Patients"
"I'm interested in value and affordability," said 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 "denial by delay," she said.
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. And, in 2019, patients spent more than $16 billion out-of-pocket on their cancer treatment, a report by the National Cancer Institute found.
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 published in JAMA in October. Another recent study found that major insurers issued "unnecessary" initial denials in response to imaging requests, most often in endocrine and gastrointestinal cancer cases.
The federal government is weighing new rules designed to improve prior authorization for millions of people covered by Medicare, Medicaid, and federal marketplace plans. The reforms, if implemented, 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.
In the meantime, patients — many of whom are facing the worst diagnosis of their lives — must navigate a system marked by roadblocks, red tape, and appeals.
"This is inhumane and unusual," said Dr. Rodriguez, a radiation oncologist. A two-week delay could have fatal consequences, and the fact that it continues to occur is "unacceptable," he said.
Dr. Rodriguez's research has also revealed that prior authorization is directly linked to increased anxiety among cancer patients, eroding their trust in the healthcare system and wasting both the provider's and the patient's time.
John Anderson, 58, of Seattle, Washington, was diagnosed in 2020 with pancreatic cancer. After six months of chemotherapy last year, his insurance company denied the recommended surgery, deeming it medically unnecessary.
"I remember feeling devastated. I need this surgery to have a chance at survival," Anderson said. After fighting his insurer's denial "relentlessly," Anderson said, the insurance company eventually approved the surgery. The insurer did not respond to requests for comment.
Anderson described the entire process as "extremely traumatic."
"You have to navigate through the most complex system imaginable," he said. "If you just sit there waiting for them to take care of you, they won't."
A recent study found that patients who are covered by private insurance appear to be particularly affected by prior authorization, regardless of their health concerns. About 1 in 5 adults with private insurance reported that their insurer had denied or delayed prior approval for a treatment, service, visit, or medication — double the rate of adults with government-provided insurance.
Patient Push Back Against Health Insurance Denials
In some cases, patients are pushing back.
In November, it was revealed 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 that the company had "crossed the line" in denying treatment for a man with lymphoma. And Blue Cross and Blue Shield of Louisiana "met its match" when the company denied a Texas trial lawyer's cancer treatment, also in November.
Countless others have turned to social media to shame their health insurance companies into approving prior authorization requests. Legislation has been introduced in at least 30 states — from California to North Carolina — to address the problem.
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.
In many ways, his story echoes the national VA scandal from nearly a decade ago, in which veterans across the country were languishing — some even dying — as they waited for care.
In 2014, a veteran named Thomas Breen was subjected to long wait times at the VA in Phoenix. Unfortunately, he passed away from stage 4 bladder cancer before he could even get an appointment.
Now, another patient named Winters is facing a similar situation. His cancer has spread to his lungs and he has been diagnosed with stage 4 cancer.
Teresa Winters, his wife, expressed her frustration with the VA's broken processes, stating that nothing has changed.
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KFF Health News, formerly known as Kaiser Health News, is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
