New data prove a point that clinicians and advocates have been making for years: Prior authorization hurts patients.
A study published in Arthritis Care & Research looked at delays associated with obtaining insurance approval before a patient could receive infused medication. The research team found that:
- Patients whose insurance required prior authorization waited almost twice as long to begin treatment.
- For patients with rheumatic conditions such as arthritis, lupus or gout, that meant twice as much exposure to corticosteroids.
Steroids help decrease inflammation. They also suppress the immune system, reducing flare-ups. But prolonged use increases the risk of infection, diabetes and cardiovascular disease – unnecessarily, given that nearly all prior authorizations for the prescribed infused medication were eventually approved.
Delaying patients’ access to their physician-prescribed treatment not only harms patients’ health, but also drives up health care costs system wide. The process leads to more office visits and extra labs for patients; the hours providers and their staff spend on completing forms and filing appeals inflates administrative overhead too.
“Many health care plans now use prior authorization indiscriminately, ensnaring the treatment delivery process in webs of red tape,” noted Paula Marchetta, MD, of the American College of Rheumatology. She called the barriers “gratuitous hurdles for patients and providers.”
Meanwhile, Congress is considering a measure to streamline and standardize prior authorization within the Medicare Advantage program. The bipartisan “Improving Seniors’ Timely Access to Care Act” would:
- Create an electronic prior authorization program. A new system would facilitate electronic transmission of requests and responses in real time.
- Improve transparency. The law would require plans to report to the Centers for Medicare & Medicaid Services their use of prior authorization and denial rates. It would also mandate that plans’ protocol undergo an annual review to ensure they adhere to evidence-based medical guidelines.
- Increase oversight. The new reporting and scrutiny can ensure Medicare Advantage plans make timely determinations and don’t use prior authorization on certain medically-necessary services.
The bill is popular among patients, physicians, health care professionals and stakeholder groups. The Alliance for Patient Access was one of more than 370 organizations to submit a letter in support of H.R. 3107.
These reforms, if adopted, would help the roughly 22 million seniors enrolled in a Medicare Advantage plan.