Bureaucracy claimed a 19-year-old victim in October 2009 and her case is still being litigated today. The suddenly required prior authorization for Yarushka Rivera’s necessary-to-live Topomax defied common sense. Caught between an unaffordable $400 out-of-pocket cost, unresponsive prescribing physician’s office, and lip service from the pharmacy, Rivera suffered a fatal seizure and died. Her death was preventable, had she been able to receive the life-saving medication. Rivera’s insurer was MassHealth, Massachusetts’ combined Medicaid and CHIP program.
Generally, the function of prior authorizations is to eliminate waste, fraud, and abuse, and to direct patients to widely-used procedures and medications. For example, there’s a common OTC toenail fungus medication that’s been available for years. A newer medication, which may or may not be better, is also available, and it costs 50-100 times more than the existing medication. If your physician prescribes the newer drug, they have to make a case to your insurer why you should use it versus the older, cheaper drug.
In Yarushka Rivera’s case, she was being kept alive by taking Topomax, and she couldn’t afford the full-priced medication. Lack of insurer, pharmacist, and provider education compounded by poor procedures led to the loss of a beautiful life.
Walgreens, MassHealth, and the prescribing physician are all culpable. No follow-up and no legally-enforced reason to be culpable caused this situation. Each party should be made accountable and should spend the rest of their lives remembering this casualty of bureaucracy. If employer-sponsored insurance were involved, then the employer and their insurance carrier would be accountable as well, since most Americans receive health insurance through their employer. Health insurance entails a financial safety net and access to healthcare. Access was denied, through a high financial barrier and flaming bureaucratic hoops. No one did their job, as facilitators of healthcare and healers. The provider, pharmacy, and insurer did harm. Shame on them all.
Melissa Walton-Shirley, MD, "The Death of Yarushka Rivera: Prior Authorization Run Amok," Medscape, 19 June 2018, https://www.medscape.com/viewarticle/898244?src=wnl_mdplsnews_180622_mscpedit_wir&uac=276724BZ&impID=1664879&faf=1