Prior Authorizations: Time to Rebel?

Dinah Miller, MD


April 06, 2023

I imagine I am not alone when I tell you that my blood pressure rises every time I receive an email from CoverMyMeds, or worse, a phone call from a patient to tell me the pharmacist says I need to call their insurance company to get a medication authorized. Prior authorizations (PAs) are the bane of every physician's existence.

Pharmacy benefit managers (PBMs) and insurers determine what treatment patients may have without regulation, accountability, liability, or transparency. They ask providers to jump through hoops, and no one oversees the placement of these hoops. The process puts patients at risk and sucks the joy from the practice of medicine.

In fall 2021, the legislative committee of the Maryland Psychiatric Society (MPS), with the help of Kathy Orellana and Tim Clement from the American Psychiatric Association, drafted a bill to modify the use of PAs. Unfortunately, the bill died in committee during the 2022 Maryland General Assembly legislative session.

Robert Herman, MD, who helped draft the initial legislation, was delighted when he learned that MedChi, the Maryland State Medical Society, had taken the proposed legislation and expanded it. "It was everything we wished for and more," Herman said.

During this year's legislative session, House Bill 305/Senate Bill 308, Health Insurance — Utilization Review — Revisions, was sponsored by 19 delegates and two senators. Fifty medical associations, including dentists and physical therapists, endorsed the bill. Many people, including Herman, testified before the Health and Government Operations Committee on February 16.

Delegate Kenneth Kerr introduced the legislation to the committee.

"Before I begin, let me make two points. First, the bill does not do away with prior authorization or other utilization review techniques; rather, it tries to make a more balanced approach for both patients and physicians by attempting to reduce the volume that's subject to prior authorization, by increasing transparency and communication, and by studying how the process can be improved overall. Second, we have over 50 organizations representing healthcare providers and patient advocacy organizations supporting this legislation. This is a systemic issue across the entire spectrum of healthcare," said Kerr.

Kerr went on to say there were 81,143 denials for treatment in 2021. The three areas with the highest rate of denials were pharmacy, dental, and the combination of labs and radiology.

He further noted that when consumers filed a complaint with the Maryland Insurance Administration, 72.4% of denials were reversed in 2022.

"This resulted in more benefits that could have, and should have, been given to the patient at the first request. These reversals indicate there is a problem," Kerr said. He discussed increased administrative costs, the enormous workload burden this incurs, and the problem of burnout among medical providers.

The proposed legislation includes a ban on PA requirements for generic medications, for dose changes of previously authorized medication, and ends the requirement for yearly authorizations. It requires that a physician of the same specialty be on the panel that denies care and shortens the time periods allowed for responses and appeals.

Testimony began with those supporting the legislation. Doctors highlighted the harm inflicted on their patients by the PA process. An oncologist spoke of how it took weeks to get approval for chemotherapy for a patient with an aggressive cancer, a gastroenterologist discussed a patient who became ill and lost her job when successful treatment for inflammatory bowel disease was stopped while she waited for the yearly medication reapproval, and another physician told of a patient who died of an exacerbation of obstructive lung disease, also while awaiting a yearly reapproval for an effective medication.

A dentist spoke about how he was not authorized to crown on a patient's tooth. Instead, he was instructed to try a filling first, and when the filling failed, he was told he would not be authorized to work on the same tooth twice in one year.

A physical therapist testified that PA was required every two to four sessions, and each request took up half of a session — a significant portion of time that was not used for treatment.

Three people testified in opposition to the bill. Matthew Celantano, executive director of the League of Life and Health Insurers of Maryland, called the legislation "drastic" and testified that the cost would be prohibitive.

"From our end, it's important for you to hear that prior authorization is care coordination. It's protection that keeps [patients] safe, but helps control skyrocketing healthcare costs," said Celantano.

Deb Rivkin, vice president of government affairs for CareFirst Blue Cross Blue Shield, testified in favor of using better technology. She cited legislation under consideration in Virginia that would give clinicians more information about the specific medications that require PAs, price information, and real-time authorizations.

Finally, representing the Pharmaceutical Care Management Association, Heather Cascone testified about PAs for generic medications. Her testimony focused on prior authorization for generic medications. She claimed that "…by allowing unrestricted dispensing of generic drugs, or an override based on the subjective opinion of the prescriber, prior authorization can protect patients from drugs with a safety risk; they can catch things like drug-disease contraindications, dosage errors, pregnancy-related contraindications, and a variety of cost-savings protections."

I found this testimony particularly difficult because the "protector" is generally not a physician and has neither seen, nor examined, the patient. The implication that patients need protection from their doctors who would be unaware aware that they are pregnant, or are ill, was offensive. It also implies that PBMs are lax by not requiring PA on all medications, ignoring the fact that patients often bypass such denials by paying out of pocket for treatment.

If this had been a high school debate, there would be no doubt the enthusiasm for the bill for HB305 was strong, the committee chair was eager, and the arguments in favor of the legislation robust. There are no public minutes for the subsequent meetings with stakeholders, and I was somewhat heartbroken to learn that once again, the bill died in committee.

Annette Hanson, MD, chair of the MPS legislative committee, remains optimistic for the future. "Since then, the APA [American Psychiatric Association] has taken our bill and used it as model legislation now being offered to other district branches. MPS has created something that is going to spread across the country. Change may be slow, but it is not inevitable. And when it happens, I want you to remember that it started here," she said.

However, the pressure is on. A recent ProPublica article documented how Cigna doctors rejects claims by the batch without ever reviewing them. Soon after that piece was published, it was announced that several of the large insurers, including Cigna, would be cutting back on PA demands. It remains to be seen whether this is a token move to placate legislators, and whether it will provide meaningful relief to physicians and patients. I remain skeptical.

In the meantime, physicians' ability to help their patients remains compromised and administrative tasks consume valuable time. I have started to wonder whether there may be some other way to push this issue to action. PA is about cost containment, but perhaps there are other ways to economize.

Why do medications cost less in other countries? Why does a medication cost hundreds of dollars more at one pharmacy vs another? Why do medicines sometimes have a copay that is two or three times higher than the cash price? Why do some covered medications have copays of thousands of dollars a year? I wonder if physicians shouldn't come together and collectively agree not to comply and refuse to complete PAs in organized rebellion.

The fear, of course, is that such an endeavor would hurt patients, but if we all agreed in concert, then for better or for worse, something would have to give. The existing system is already hurting everyone, and physicians, by agreeing to play this awful game, are complicit in letting insurers dictate the care our patients receive.

Dinah Miller, MD, is a co-author of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.

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