Believing the pendulum has swung too far and often results in delays for patient care, physicians want state legislators to curtail the ability of health insurers to require prior authorization to cover a medical test, procedure or medication.
The Michigan State Medical Society, working with patient advocates in a coalition called Health Can’t Wait, backs a bill introduced this week in Lansing to reform health insurers’ prior authorization practices. The legislation also targets so-called step therapy, in which insurers require patients to undergo an alternative treatment or try a lower-cost drug and “fail first” before covering the physicians’ preferred option.
The Health Can’t Wait coalition argues that prior authorization in recent years has grown from requirements on higher-cost procedures, tests and medications to now affecting routine medical services.
“This is about the escalation of what is being prior-authorized,” said Christin Nohner, director of state and federal government relations for the Michigan State Medical Society, an East Lansing-based group that represents more than 15,000 physicians across the state.
State Sen. Curt Vanderwall, R-Ludington, who chairs the Senate Health Policy Committee, introduced the bill, which would require health insurers to post prior authorization requirements on their website so they are readily available, and to annually report statistics on pre-authorization approvals and denials.
Health insurers also would have to provide physicians with an answer within 24 hours on authorization for care they deem “urgent” and within 48 hours for non-urgent care. The bill also defines an appeals process for care denials and would prohibit step therapy for a drug if a physician considers it not in the “best interests” of a patient.
In a statement from the Health Can’t Wait coalition, Trudy Ender, executive director of the Susan G. Komen Foundation of Michigan, said prior authorization and step therapy “are needlessly jeopardizing the health and well-being of patients around Michigan every single day.
“That’s all anyone should need to hear to know that reform is necessary,” Ender said.
In advocating for the legislation, Health Can’t Wait points to a 2018 American Medical Association survey in which 28 percent of responding physicians said prior authorization resulted in at least one serious adverse event, such as hospitalization, disability, permanent harm to a patient, and even death. Three-quarters said prior authorization had led some patients to abandon treatment.
“Prior authorization, step therapy and fail first requirements aren’t just a hassle for patients — they threaten their health,” said Dr. S. Bobby Mukkamala, a Flint area ear, nose and throat specialist and president-elect of the Michigan State Medical Society.
Health insurers using prior authorization as a check against high costs are sure to oppose the legislation.
“We see step therapy and prior authorization as a pathway to coverage and care. Prior authorization is an essential part of health care cost management,” said Andy Hetzel, vice president of corporate communications for Blue Cross Blue Shield of Michigan. “These processes are collaborative with physicians and ensure that patients receive the right care, at the right time, at the right cost. Particularly for expensive and high risk prescription drugs and medical procedures, our customers want to ensure the care being delivered is appropriate.”
A MATTER OF WASTE?
The Michigan Association of Health Plans, which represents HMOs in the state, has “real concerns” about the bill, said Jeff Romback, the group’s deputy director of policy and planning.
Dating back more than 50 years, the practice of prior authorization and step therapy requirements are “guardrails” designed to drive down waste and curtail the unnecessary use of costly tests, procedures and drugs when less-expensive alternatives may work just as well for a patient, Romback said.
“We’re being the stewards, in most cases, of employer groups,” he said. “These are meant to ensure the right care is being delivered at the right time, to the right person, and delivered in the right setting of care.”
Research shows prior authorization and step therapy generate “real savings,” Romback said.
Romback cites a report this month by the Journal of the American Medical Association that estimated waste in the U.S. health care system at $760 billion to $950 billion annually. The report pegged the cost of “overtreatment or low-value care” at $75.7 billion to $101.2 billion a year.
The MAHP specifically objects to provisions in the bill that would allow doctors to override prior authorization and step therapy requirements, he said. Physicians can easily game the system by tagging requests as “urgent.”
“When you have a situation where most doctors don’t know the cost of the drug or the cost of the care that they’re prescribing, and if you don’t know the cost and you go and you prescribe it with blinders of what the cost is, you could be pushing cost onto the member (of a health plan) if they have a high-deductible plan,” Romback said. “If somebody else has taken a look at the program and said, ‘Hey, have you tried these less costly steps first’ and you’re overriding that, that seems to put a lot of authority on a group that’s not at risk for any of those costs.
“When you’re not at risk and you don’t see the cost of it, you’re unaware of it, you have every incentive to call it ‘urgent.’”
Romback also points to a study issued in April 2018 by the federal Government Accountability Office that suggests prior authorization “may be used to reduce expenditures, unnecessary utilization, and improper payments” for Medicare and Medicaid, although the effect is hard to quantify and difficult to separate “from other program integrity efforts,” according to the report.
FINDING MIDDLE GROUND
The Michigan Health & Hospital Association (MHA) has yet to take an early stance on the legislation, but will review it soon.
Work to reform prior authorization is “a responsible, cautious step toward reducing burdens on patients, providers and payers while still keeping measures in place for high-cost, complex services,” the MHA said in a statement.
“Our first priority at the MHA is always the health, safety and quality of care delivered to patients. To that end, we support modernizing the current structure of prior authorization requirements by insurers to better reflect the current needs of patients,” according to the MHA. “We also appreciate the need to be mindful of costs, especially in today’s health care environment when medications and specialty treatments can be extremely expensive for all stakeholders.”
The Medical Society expects the legislation will not get to a committee hearing until January, as other issues, such as legislation regarding surprise billing in health care, takes priority.
Romback contends that health plans are already constantly reviewing and altering policies and practices for prior authorization and step therapy.
Despite its objections, the Michigan Association of Health Plans is willing to work out a compromise, although “some of the stuff in the bill, it’s awfully one-sided,” Romback said.
“If we can find a way to work with MSMS to drive value through this process and improve value to the patients, and improve value to employers, we’re very open and very willing to enter into those conversations,” he said. “There’s some middle ground.”
However, Kevin McFatridge, senior director of marketing and public relations for the Michigan State Medical Society, said common ground may prove hard to find.
“When you talk about delays in patient care, I don’t know there is much room for negotiations. We want to make sure the patients get the care they deserve and in the time they deserve it,” McFatridge said. “When you have cancer, do you want your care delayed or do you want it to start as soon as possible?”