Help, not hassle
Additional reforms to prior authorization will assist Texans with timely medical care.
It only makes sense. When a doctor prescribes an experimental or especially expensive medication or treatment, the first call is to the insurance company to make sure it’ll pick up the tab. But too often in Texas that common-sense requirement turns out to be a hassle, rather than a help, and can sometimes cause life-threatening delays.
That’s what’s behind a push in the Texas Legislature by the Texas Medical Association, which is lobbying for additional reforms after partially addressing the problem two years ago. Doctors claim that prior authorization requirements have progressively expanded, requiring more of doctors’ time, negatively impacting patients and — many believe — only padding insurers’ pockets.
We’re sympathetic to insurers’ argument that without the need to get prior authorization, the cost of medical care could skyrocket, but the doctors aren’t seeking to get rid of prior authorization altogether. They’re asking for rules that will allow sensible exceptions.
“Many patients just end up paying for needed procedures out of pocket, because they don’t want to wait on the insurance company getting back or they’ve been denied,” said Clayton Stewart, TMA associate director for advocacy. “When you’re paying a premium every month on your insurance, you really should have that coverage.”
Not all services or drugs require prior authorization, but a survey of Texas doctors found that 80 percent of them reported having to obtain prior approval for medical procedures, while 85 percent had done so for prescription medications, even when what is prescribed is common or a generic prescription. Physicians said that on average they complete 31 prior authorization requests a week.
Most of the time, obtaining clearance led to delayed patient care, the survey found, with some patients choosing to abandon treatment altogether.
Even when successful, the process can be frustrating, said Dr. Debra Patt, an Austin oncologist. A recent prescription for a patient with metastatic breast cancer was denied by the insurance company and on her appeal, she was referred to a peer review with a family practitioner.
“He tried to insist to me that the patient had progressed on (cancer drug) Herceptin, so she didn’t need Herceptin again,” Patt told the editorial board. “And I said, ‘Don’t you know that this is the standard of care?’”
It took several phone calls and more than an hour to settle the matter, she said.
Health insurance providers also argue that prior authorization protects patients, keeping them from risky procedures and unnecessary tests. It also safeguards patients by insurers having an overall picture of care that individual doctors may lack.
“We’re the only ones that have that 360 view of what is going on with the patient to know that there was going to be an adverse reaction between two or three drugs, or between a surgery and another drug,” said Jamie Dudensing, CEO for the Texas Association of Health Plans.
Controlling their costs is important, she added, but those savings come from keeping overtreatment in check, which also benefits patients.
That may be a hard pill to swallow — that in demanding prior approval insurers are as focused on patient health as their own bottom lines — but it’s clear that sometimes it helps to require doctors to justify major treatments or additional tests.
Keeping Texans safe should be the priority for lawmakers. They should avoid legislation that offers a blanket removal of prior authorization, such as HB 1145, which would exempt in-network service providers from the requirement. They should instead focus on bills such as HB 907, which protects prescriptions for chronic or autoimmune diseases, and HB 410, which removes prior authorization requirements from state-mandated benefits for health care plans, including mammography, mastectomy and diabetes management.
For the Legislature, the goal must be to balance efforts by health insurers to limit costs with the need to reduce administrative burdens on physicians — not for their sake alone, but so that they can provide timely medical care to Texans in need.