By Erica Palmer Smith
The term “prior authorization reform” sounds like boring insurance jargon, but the issue is critically important to patients’ well-being. American Cancer Society Cancer Action Network (ACS CAN) and its partners will work on legislation to address the problems that can arise with prior authorization during the 2019 session in Kentucky.
ACS CAN, the American Cancer Society’s nonprofit, nonpartisan advocacy affiliate, empowers advocates across the country to make their voices heard and influence evidence-based public policy change as well as legislative and regulatory solutions that will reduce the cancer burden.
Right now, health insurance companies can take their time as they decide whether they will cover a certain medication or treatment. They can require prior authorization and there is no limit to how long they can deliberate. But, delayed care can mean patients are declining or suffering unnecessarily.
Pins and Needles
An ACS CAN volunteer shared an example. Her father was going through a second round of treatment for prostate cancer after the disease returned. His doctor prescribed two drugs that work together. The first medication did not need prior authorization, but the second did. The volunteer said the second medication took more than a month to be approved, while the family waited on pins and needles, hoping the cancer was not progressing in the meantime. Her father finally received the prescribed medications and continues his fight, but the volunteer pointed out it was a needless hurdle for a treatment that was both recommended by his doctor and eventually approved for coverage.
Maximum Approval Time
The legislation ACS CAN supports addresses these issues by establishing a maximum approval time of 48 hours for typical requests and 24 hours for urgent requests. Enhanced efficiencies would be achieved by reducing administrative burdens for physicians through an improved electronic submission system. In addition, the legislation ACS CAN supports requires that prior authorization approvals must be honored for a plan year for medications that treat a chronic disease.
Current prior authorization practices can be wasteful and time-consuming for cancer patients and their physicians, which is particularly confounding when you consider that 80 percent of prior authorization requests are ultimately approved. We need legislation to streamline the prior authorization process, to make it a timelier and more transparent for patients and their family members.
According to the most recent data from the American Medical Association, the average physician spends more than 15 hours per week on prior authorization work for their patients. In addition, Health Affairs reports that prior authorization requirements and other administrative burdens cost $82,975 per physician per year.
Once your doctor has determined the best course of treatment, getting an answer from your insurance company about coverage should not be an epic endeavor. It should be a simple yes or no, respectful of the fact that time is of the essence. That is why ACS CAN is taking on this issue and working toward a positive resolution in this legislative session.
Legislation ACS CAN Supports
- Establishing a maximum approval time of 48 hours for typical requests and 24 hours for urgent requests.
- Enhanced efficiencies would be achieved by reducing administrative burdens for physicians through an improved electronic submission system.
- Prior authorization approvals must be honored for a plan year for medications that treat a chronic disease.
-Erica Palmer Smith is the American Cancer Society Cancer Action Network Kentucky government relations director.