Ky. health-care providers lobby for bill that would ease health insurers' required prior authorization for medical procedures

OPINION by health-care provider groups listed below

It’s a situation all of us will find ourselves in at some point. You’re sick, or get diagnosed with a chronic condition, or need to have surgery. Thankfully, your physician diagnosed the issue quickly and a treatment plan was made, and you have health insurance to cover it. You should be on your way to health and healing, right?

Unfortunately, thanks to something called a “prior authorization,” there’s a good chance your care is about to get delayed or denied by your insurance company.

Prior authorization is a complicated, time-consuming, “cost-control process” utilized by health-insurance companies that requires physicians to obtain advanced approval from them before a specific service or medication is delivered. That’s right: your health plan can delay or deny the care that your physician prescribes in an effort to sway them towards a less effective treatment or service. There is no question that this negatively impacts patients and providers by leading to care delays for patients, administrative burdens for you and your physician, and increased overall costs to the health-care system.

Photo illustration from MedicalAlgorithms.com

Recent surveys and reports support the need to reform this system. A 2022 Kentucky Medical Association survey found that 82% of physicians said that issues related to the prior authorization process sometimes, often, or always lead to patients’ delays or changes to patients’ recommended course of treatment. Another national survey found that physicians spend a median of four hours per week on drug utilization management, while nurses spend 15 hours and other staff spend between 3.6 and 10 hours per physician per week. That is time that medical practices and professionals could surely put to better use on patient care.

However, the biggest impact is, of course, on the health of patients. 81% of those surveyed by KMA said the prior-authorization process delays access to necessary care for patients sometimes, often or always. One physician told of an oncology patient denied anti-nausea medication because of a required prior authorization. In the approximately three-day interval it took to get the authorization from the insurer, the patient was readmitted to the hospital with nausea, vomiting, dehydration, renal failure and electrolyte abnormalities. Another physician described a diabetic patient who did not receive their insulin as prescribed due to need for a prior authorization and had to go to the emergency department for care.

Of course, hospital admissions and visits to emergency rooms don’t save money, as prior authorizations are “intended” to do. Delaying necessary care can lead to complications and worsen the health of patients. And in the end, the vast majority of prior authorizations are approved, either initially or on appeal. This process is, therefore, unnecessary.

That’s why our organizations and thousands of our physician members across the state are calling for reform. During last year’s legislative session, KMA advocated for the passage of a bill which would have streamlined this process. The new program would ensure patients have timely access to the care they need, reduce administrative burdens for physicians, and lower healthcare costs. Together, we will be advocating for the passage of this legislation in the 2024 session.

Kentucky patients who are already suffering from chronic conditions and illnesses don’t need their care delayed by an insurance company. Let’s reform the prior authorization process to improve the health of our commonwealth.

This was written by the Kentucky Medical Association; Falls City Medical Society; Kentucky Association of Indian Physicians; Kentucky Chapter of the American College of Physicians; Kentucky Academy of Family Physicians; Kentucky Society of Anesthesiologists; Kentucky Dermatological Association; Kentucky Chapter of the American College of Cardiology; Kentucky Psychiatric Medical Association; and Kentucky Society of Addiction Medicine, via Ashley Bitters at ashley@runswitchpr.com. For a health care journalist’s guide to prior authorization, from Journalists' Resource at Harvard University, click here. The legislation, House Bill 317, was filed Thursday by Republican Reps. Kim Moser of Taylor Mill and Robert Duvall of Bowling Green.