Wrote a prior auth justification letter at 10pm for a medication I prescribe weekly

Started a patient on semaglutide Tuesday. Straightforward clinical decision. A1c of 8.9, already failed metformin and a sulfonylurea, BMI 34, documented cardiovascular risk factors. Textbook indication.

The pharmacy kicked it back. Plan requires step therapy documentation. I need to write a letter demonstrating medical necessity with dates of prior therapies, duration of each trial, reasons for failure, current lab values, and a clinical rationale citing guideline support. The EHR has all of this information scattered across four years of visit notes, two medication lists, and a lab history that requires scrolling through dozens of results to find the relevant ones.

So Wednesday night, pajama time, I started reconstructing a clinical narrative the EHR already contains but cannot assemble. I pulled the metformin start date from a 2022 note. The sulfonylurea trial dates from a 2023 note. The side effect documentation from a follow up visit. The A1c trajectory from the lab tab. Formatted it into a letter nobody at the insurance company will read carefully but everyone requires me to produce.

I write some version of this letter 2-4 times per week. For GLP-1s. For CGM sensors. For insulin pumps. The clinical question was answered months ago. The insurance company re-litigates it every time.

A 2024 AMA survey found physicians and their staff spend an average of 13 hours per week on prior authorizations. 39 requests per physician per week. 89 percent of physicians said the process contributes to burnout. 29 percent reported it led to a serious adverse event for a patient, including hospitalization.

There are two failures here. The first is an insurance system that requires physicians to repeatedly justify evidence based prescribing for medications they have prescribed hundreds of times. The second is an EHR that stores every data point needed for that justification but cannot assemble it into the letter the insurer demands. The physician becomes the manual bridge between a payer that requires proof and a record system that cannot produce it.

The EHR stores the medication history, the lab trajectory, the diagnosis timeline, the prior trial dates. Assembling that into a payer ready letter should be a system function, not a Wednesday night project.