John Barbieri, MD, MBA, discusses how deteriorating prior authorization processes are compromising access to essential dermatologic therapies.
“Now, I feel like the process has continuously become more of an effort to delay care, both with the standpoint of initial letters and denials and appeals, where there's a general lack of transparency and engagement,” said John Barbieri, MD, MBA, in a recent interview.
Barbieri, a dermatologist and director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital in Boston, Massachusetts, and an associate professor of dermatology at Harvard Medical School in Cambridge, recently co-authored a paper, “
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In his latest interview, Barbieri discusses his experience with the changing quality of peer-to-peer calls, how patients may be negatively impacted by delay increases, and his ideas for policy change and reform. He also reviewed additional research he is working on, including smartphone-delivered cognitive behavioral therapy for patients with psoriasis.
Barbieri described a steady deterioration in the integrity of dermatology prior authorization workflows. Earlier in his career, peer-to-peer reviews felt collaborative, with space for evidence-based discussion and respect for clinical judgment. Now, he sees a system built around delay: vague criteria, rushed denials, and appeals that lack meaningful engagement. Even at the peer-review stage, clinicians frequently encounter reviewers outside the specialty who do not consider clinical rationale and simply reiterate predetermined criteria. According to Barbieri, this effectively nullifies the intended purpose of peer review and pushes cases into third-party appeals that are rarely successful and prolong patient suffering.
Barbieri emphasized that prolonged authorization timelines create avoidable morbidity for patients with dermatologic disease. Even when an approval is ultimately granted, the cumulative delays increase the risk of complications and prolonged symptom burden. He noted that resource stewardship is appropriate, but current “delay and deny” patterns do not reflect thoughtful allocation. Instead, they obstruct access without transparency or accountability.
To restore functional utilization management, Barbieri called for basic structural reforms: clear identification of decision makers on determination letters, standardized presentation of covered alternatives and step-therapy requirements, and mechanisms to enable true evidence-based dialogue. He argued that payers should be required to stand behind their criteria if these policies are intended to reflect appropriate clinical care. Legislative mandates may be necessary to ensure transparency and enforceable standards.
Barbieri highlighted the need for further study on peer-to-peer interactions, which were not included in his recent research on initial and appeal denials. Understanding how often these calls genuinely facilitate clinical engagement versus functioning as symbolic hurdles is a key next step.
He also discussed ongoing work to address broader comorbidities in chronic inflammatory skin disease. In collaboration with multiple academic partners, his group recently piloted smartphone-delivered cognitive behavioral therapy for patients with psoriasis. In this 30-patient study, participants experienced improvements in depression, anxiety, and dermatology-specific quality of life, suggesting technology-enabled mental health interventions may augment overall disease management. Further investigations are underway to expand this approach.2
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