In what could be a model for other states, Texas has become the first state to exempt physicians from prior authorizations for meeting insurer benchmarks.
The law was passed in June and will take effect in September. It excuses physicians from having to obtain prior authorization if, during the previous 6 months, 90% of their treatments met medical necessity criteria by the health insurer. Through this law, doctors in the state will spend less time getting approvals for treatments for their patients.
Automatic approval of authorizations for treatments — or what the Texas Medical Association (TMA) calls a “gold card” — “allows patients to get the care they need in a more timely fashion,” says Debra Patt, MD, an Austin, Texas–based oncologist who’s the former chair of the council on legislation for the TMA.
Eighty-seven percent of Texas physicians reported a “drastic increase over the past five years in the burden of prior authorization on their patients and their practices,” per a 2020 survey by the TMA. Nearly half (48%) of Texas physicians have hired staff whose work focuses on processing requests for prior authorization, according to the survey.
Jack Resneck, Jr, MD, a San Francisco–based dermatologist and president-elect of the American Medical Association (AMA), says other states have investigated ways to ease the impact of prior authorizations on physicians, but no other state has passed such a law.
Administrative burdens plague physicians around the country. The Medscape Physician Compensation Report 2021 found that physicians spend on average 15.6 hours per week on paperwork and administrative duties.
Better Outcomes, Less Anxiety for Patients
Patt, who testified in support of the law’s passage in the Texas legislature, says automatic approval of authorizations “is better for patients because it reduces their anxiety about whether they’re able to get the treatments they need now, and they will have better outcomes if they’re able to receive more timely care.”
Recently, a chemotherapy treatment Patt prescribed for one of her patients wasn’t authorized by an insurer. The result is “a lot of anxiety and potentially health problems” for the patient, says Patt.
She expects that automatic approval for treatments will be based on prescribing patterns during the preceding 6 months. “It means that when I order a test today, the [health insurer] looks back at my record 6 months previously,” she says. Still, Patt awaits guidance from the Texas Department of Insurance, which regulates health insurers in the state, regarding the law.
Resnick says the pharmacy counter is where most patients encounter prior authorization delays. “That’s when the pharmacist looks at them and says, ‘Actually, this isn’t covered by your health insurer’s formulary,’ or it isn’t covered fully on their formulary.”
One of Resneck’s patients had a life-altering case of eczema that lasted many years. Because of the condition, the patient couldn’t work or maintain meaningful bonds with their family. A biologic treatment transformed his patient’s life. The patient was able to return to work and to re-engage with their family, says Resneck. But a year after his patient started the treatment, the health insurer wouldn’t authorize the treatment because the patient wasn’t experiencing the same symptoms.
The patient didn’t have the same symptoms because the biologic treatment worked, says Resneck.
Kristine Grow, a spokesperson for America’s Health Insurance Plans, a national association for health insurers, says, “The use of prior authorization is relatively small — typically, less than 15% — and can help ensure safer opioid prescribing, help prevent dangerous drug interactions, and help protect patients from unnecessary exposure to potentially harmful radiation for inappropriate diagnostic imaging. Numerous studies show that Americans frequently receive inappropriate care, and 25% of unnecessary treatments are associated with complications or adverse events.”
Medical management tools, such as prior authorization, are an “an important way” to deliver “safe, high-quality care” to patients, she added.
State and Federal Efforts to Curb Prior Authorization
In addition to efforts to curb prior authorization in other states, the AMA supports the Improving Seniors’ Timely Access to Care Act (HR 3173). The act includes a provision related to “gold-carding,” says Robert Mills, an AMA spokesperson.
The bill establishes requirements and standards for prior authorization processes related to Medicare Advantage (MA) plans. The requirements and standards for MA plans include the following:
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Establishing an electronic prior authorization program that meets specific standards, such as the ability to provide real-time decisions in response to requests for items and services that are routinely approved;
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Publishing on an annual basis specific prior authorization information, including the percentage of requests approved and the average response time;
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Meeting standards set by the Centers for Medicare & Medicaid Services related to the quality and timeliness of prior authorization determinations.
The act was introduced to the US House of Representatives in May, after which it was referred to two committees for consideration.
Aine Cryts is a veteran health IT and healthcare writer based out of Boston.
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