This week, I had the privilege of moderating a Capitol Hill briefing that brought together physicians, researchers and patient advocates to confront a growing crisis: insurance denials and their impact on care. The briefing focused on the findings of a landmark analysis, "70% DENIED: How insurance denials are delaying and preventing care for millions of Americans."
Medicines can’t be taken if they’re denied. Throughout the discussion, panelists shared a consistent message: When medically appropriate medicines are delayed or denied, the insurance process is failing patients and providers through disruptions in care, the undermining of clinical decision-making, and potentially worsening outcomes.
The panel reflected a broad range of experiences and expertise:
- Representative Greg Murphy, MD (R-NC)
- Rahel Ehrenberg, Principal Researcher, IQVIA
- Dr. Harry Gewanter, FAAP, MACR, Coalition of State Rheumatology Organizations
- Peyton Pipher and Alex Winchester, Voters for Cures advocates
Representative Greg Murphy, MD (R-NC) opened the briefing by sharing his own experience with insurance denials. As he put it, "The purpose of a medicine is to be taken," Murphy said, describing being denied coverage, appealing, and being denied again, highlighting how repetitive barriers are designed to exhaust both patients and providers.
"I would submit that the average patient gives up after two tries. And the average physician, on behalf of the patient, will probably give up after two tries. Because when you add up the culmination of these attempts, it does what the insurance companies want it to do: obstruct and stop the process."
The data behind the crisis. Rahel Ehrenberg, author of the IQVIA report at the center of the briefing, provided the quantitative backbone for what the other panelists described anecdotally: 70% of commercially insured patients were initially denied coverage for at least one prescribed brand medication in 2024.
- Most denials are appealed—but 3% to 10% are never challenged.
- When appeals are filed, roughly half are overturned.
Denials delay care, and many patients never make it through the process. Ehrenberg urged patients not to give up and pointed to manufacturer bridge programs — particularly in specialty and rare disease — designed to help patients access treatment while navigating the coverage gap. "If you're experiencing this, you're not alone," she said.
Patient stories: A medical student and a rare disease survivor
Two patient advocates from Voters for Cures put human experiences on the data.
- Peyton Pipher, a second-year medical student, described developing worsening asthma symptoms at the start of school. Despite clear medical need, his prescribed treatment was denied. He was routed through step therapy, cycling through drugs with significant side effects, before eventually accessing the treatment that he knew worked for him.
- Alex Winchester shared her experience living with pemphigus vulgaris, a rare and severe autoimmune disease. Despite her doctor's clear treatment path, she faced repeated insurance denials, and was ultimately forced to switch insurers, delaying her access to the prescribed treatment for another year. After taking the initially prescribed medication, she remains in remission.
"If that insurance company had just approved the medicine my doctor prescribed, all of this could have been avoided," she said. "For me there was only ever one drug. I had to go out and find an insurance company willing to cover it."
Physicians on the front lines of bureaucracy. Dr. Harry Gewanter estimated that 10-15% of his office time is now consumed by prior authorizations and appeals. "As physicians, we are trained to make decisions. Increasingly, that ability is being taken away." He also addressed the financial incentives driving insurers:
“The health conglomerates are now just big banks. They make money on the flow. This is not about medical care; this is about profit."
What needs to change: The panel closed with calls to action. Winchester kept it simple: "Doctors are some of the smartest people in the country. Let's give them the power to do what they were trained to do. With my rare disease, it wasn't just cosmetic, it's fatal if left untreated. We need to let doctors do what they are here to do and keep the administrative red tape out of it."
As a physician, I could not agree more. Patients deserve timely access to the medicines their doctors prescribe.
Learn more at PhRMA.org/PBMs.
Mike Ybarra
Michael Ybarra, M.D., is an emergency physician and Chief Medical Officer at PhRMA. He also serves as Senior Vice President in Advocacy and Strategic Alliances. In these roles, he leads PhRMA’s stakeholder engagement and strategic partnerships on federal and international health policy issues. He is PhRMA’s liaison representative to the Advisory Committee on Immunization Practices and is the co-convener of PhRMA’s R&D Leadership Forum. Dr. Ybarra continues to see patients clinically in the emergency department at MedStar Georgetown University Hospital.
Follow Mike on LinkedIn and X.
Mike Ybarra