Two people who are suffering from the same curable condition may need the same drug. One will get it, while the other may be prescribed something less effective. The insurance you have determines which drug you are prescribed because your insurer may require prior authorization (PA) for certain treatments. PA reform is taking shape in several states to allow patients faster access to treatments held up by bureaucratic gatekeepers. Insurance companies and payers stress the need for PA as a means of providing the right care at the right price, acting as hoops to jump through to lower the cost of health care and drive standardization.
States should reduce regulatory burdens on sick patients and their doctors. PA reform must balance the needs of the patient with the need to reduce cost. Reforms should include transparency regarding PA requirements from insurance companies and streamlining of the process to expedite approvals and cut red tape.
In Ohio, state Rep. Kevin Miller (R-District 69) recently introduced House Bill 130, which would accomplish both. Prior Authorization is a process currently used by insurance companies that requires doctors to obtain insurer approval before prescribing a treatment, diagnostic test, or other medical service. If House Bill 130 is passed, it would create a Prior Authorization Gold Card for some providers who would be exempted from certain prior authorization requirements. Physicians who are consistently (80 percent or more) approved will be granted presumptive exemptions (known as a “Gold Card”).
The legislation also requires that insurance companies “shall make prior authorization data available on its public website in readily accessible format” outlining which services are PA required and the process for denial and appeal.
Gold Card legislation first passed in Texas (HB3459) in 2021, with similar requirements. The Texas Medical Association reported an average of “31 prior authorization requests a week, taking time away from patient care. Four-fifths (85%) reported prior authorizations delayed patient care, and 78% said this can lead patients to abandon needed treatment altogether.”
The Ohio State Medical Association is joined by more than 30 other medical societies in supporting Rep. Miller’s HF130.“As physicians, we know prior authorization impacts the way we practice medicine, and our patients, every day,” said Dr. Brian Santin, OSMA President, Chief Medical Officer at Clinton Memorial Hospital and a Vascular Surgeon with Ohio Vein & Vascular, Inc. “Prior Authorization is frequently cited as not only a major contributor to administrative burden, but also a cause for delay and roadblocks to patients receiving critical treatment and care.”
A 2022 American Medical Association (AMA) survey shows PA reform is needed to address patient safety concerns. Approximately 94 percent of physicians report care delays due to the burdensome PA process. Roughly 33 percent of physicians say that PA has led to a serious adverse event for a patient. In fact, 25 percent of doctors report a hospitalization due to delays caused by the PA process and 9 percent confirm that PA led to a patients’ disability, permanent bodily damage, congenital anomaly, birth defect, or death.
The Biden/Harris administration is seeking to streamline PA through mandates on payers. The Centers for Medicaid and Medicare Services (CMS) proposed reforms to implement an electronic prior authorization process, shorten timeframes for certain payers to respond to PA requests, and make information more readily available through enhanced transparency requirements. The policy focuses on public plans and oversight.
States should recognize that although helpful, more is needed to improve the health care PA system. Legislatures should adopt common sense PA reforms to improve patient safety and redirect valuable physician time away from insurance companies and back to the patient.
The following resources provide additional information about prior authorization reform efforts:
Bills in 30 states show momentum to fix prior authorization https://www.ama-assn.org/practice-management/prior-authorization/bills-30-states-show-momentum-fix-prior-authorization The American Medical Association reviews Prior Authorization Legislation in the States
Could Texas Law on Limiting Prior Authorization Delays Move the Needle Nationwide? https://www.medpagetoday.com/special-reports/exclusives/94625 Jennifer Henderson from MedPage looks at how the “gold card” is the first step in helping physicians with the burdensome process of prior authorization.
Measuring the Scope of Prior Authorization Policies: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2780396
Why Prior Authorization is Bad for Patients and Business https://www.ama-assn.org/practice-management/prior-authorization/why-prior-authorization-bad-patients-and-bad-business Andis Robeznieks from the American Medical Association outlines what’s wrong with prior authorization
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