The Cost of Delay: How Prior Authorization Is Impacting Dermatology

In the world of dermatology today, clinicians have access to an unprecedented array of biologics and targeted treatments designed to dramatically improving outcomes for individuals living with chronic inflammatory skin diseases such as atopic dermatitis, psoriasis, and hidradenitis suppurativa (HS).^1,2

However, according to 3 dermatologists interviewed by HCPLive, gaining patients access to these drugs has evolved into a more and more complicated procedure. This, they and others in the field have noted, is due to prior authorization requirements, ‘step therapy’ protocols, and formulary restrictions caused by insurers and pharmacy benefit managers, also known as PBMs.^3,4

Prior authorization, the process by which health insurance plans go over and approve or deny various types of covered health services or medications, has evolved from an occasional administrative task into a routine part of practice management in dermatology.⁵ In this feature, the issues many clinicians have with the prior authorization process is explored, along with the potential need for future reforms.

Harrison Nguyen, MD, MBA, MPH, managing director of Harrison Dermatology & Research Group, was 1 such clinician who spoke with HCPLive about this complicated process as a substantial burden on both physicians and staff. While physicians may identify the most appropriate medication for a patient early in the visit, Nguyen highlighted the securing of a treatment’s approval as often requiring extensive paperwork, repeated communication with insurers, and dedicated personnel focused solely on navigating the authorization process.

Shannon Trotter, DO, known for her work with DOCS Dermatology Group, spoke with HCPLive about prior authorization, describing it as having long been a challenge in dermatology, though she highlighted the growing role of artificial intelligence (AI) in the process as both positive and negative. While AI tools can allow practices to better streamline submissions and diminish their own administrative workload, Trotter described insurers as also beginning to use similar technologies, creating what she described as an ongoing back-and-forth between providers and payers.

Outside of administrative burdens, all 3 of these clinicians emphasized the impact these barriers can have on patient care. Trotter pointed to step therapy requirements as a frequent source of delays, noting that patients may be required to try and fail therapies for months prior to gaining access to the medication their clinician originally recommended. During such time, a patient may continue experiencing symptoms that interfere with work, sleep, overall quality of life, or even becoming more debilitating.

Nguyen described formulary changes as also potentially forcing patients to switch from therapies that may already be working well. While some transitions occur without issue, he noted patients with conditions such as atopic dermatitis and HS can sometimes report disease worsening or loss of treatment response when required to shift between treatments for non-clinical reasons. In certain cases, Nguyen noted, interruptions in therapy can make future treatment far more challenging.

Matthew Zirwas, MD, a board-certified dermatologist at Dermatologists of Greater Columbus, spoke even more adamantly against prior authorization as a practice. Zirwas pointed to the growing number of available therapies as having intensified prior authorization challenges. He pointed to PBM rebate structures and limited transparency surrounding formulary decisions as key drivers of the issue, suggesting that treatment preferences often do not align with what clinicians believe is best for patients. Additionally, he noted his own view of the need for reforms that allow for incentives among PBMs to shift, as well as the need for more transparency.

Despite differences in emphasis, all 3 clinicians agreed that reform is needed. Proposed solutions included greater transparency around formulary and rebate decisions, streamlined authorization processes, improved peer-to-peer review systems, and reforms to step therapy requirements.

Overall, each of these 3 leaders in the field spoke in favor of a reduction of unnecessary barriers as helpful to ensure patients are given the right treatment at the right time, while nevertheless expressing the need to preserve access to the therapeutic advances known to have shaped the modern dermatologic landscape.

Disclosures: Trotter, Nguyen, and Zirwas had no relevant disclosures of note.

References

1. Amann ST, Shah ED, Wilson LJ. An Overview of the Challenging Process of Prior Authorization: Medical Necessity for a Better Way. Clin Gastroenterol Hepatol. 2024 Dec;22(12):2362-2366. doi: 10.1016/j.cgh.2024.09.001. Epub 2024 Sep 18. PMID: 39303798; PMCID: PMC11604005.

2. Sharma SP, Russo A, Deering T, Fisher J, Lakkireddy D. Prior Authorization: Problems and Solutions. JACC Clin Electrophysiol. 2020 Jun;6(6):747-750. doi: 10.1016/j.jacep.2020.04.022. PMID: 32553230.

3. Sampathkumar G. Rethinking prior authorization: bridging clinical needs and administrative burdens. Am J Manag Care. 2026 Feb 1;32(2):e31-e33. doi: 10.37765/ajmc.2026.89883. PMID: 41759204.

4. Kyle MA, Song Z. The Consequences and Future of Prior-Authorization Reform. N Engl J Med. 2023 Jul 27;389(4):291-293. doi: 10.1056/NEJMp2304447. Epub 2023 Jul 22. PMID: 37486761; PMCID: PMC10676707.

5. Wang Y, Levy JF, Mattingly TJ 2nd, Anderson G. Prior Authorization and Associated Delays and Denials of Branded Medication Dispensation. JAMA Health Forum. 2026 Apr 3;7(4):e260760. doi: 10.1001/jamahealthforum.2026.0760. PMID: 41996105; PMCID: PMC13090851.