Time to rein in the broken prior authorization system

California health care, image by Niyazz

OPINION – One of my patients was born with paralyzed vocal cords, unable to breathe on her own.  Shortly after birth, she had to have a tracheostomy, a surgical procedure that involves making an incision in the patient’s neck to insert a tube used for breathing. While the operation was successful, that surgery was unfortunately just the beginning of her travails with our health care system.

Living with a tracheostomy requires intensive and ongoing care. Unfortunately, for this little girl, and many like her, the bureaucracy of insurers has made this care more difficult to obtain.  We are often required to complete prior authorizations, a process in which a provider must ask an insurer permission to obtain a service, test, or treatment. Her family and I have spent countless hours navigating phone trees, filling out forms, and appealing decisions.

When she had an infection in her tracheostomy, her care was delayed by days causing this infant girl extreme pain as we sought approval for the appropriate antibiotic. Medical supplies are often delivered late as we struggle for insurance approval. Requests for surgeries and procedures have been denied, only to be eventually allowed after weeks of appeals and paperwork.  Not only does this process take valuable time that I could be spending caring for other patients, but it transfers critical medical decisions from patients and physicians to a corporate entity.

Living with a child with special needs is difficult, but dealing with an insurance system whose primary goal is to increase profits makes this so much tougher. Insurance companies often issue quick denials to see if the physician or patient will give up while holding onto their money during the appeals process.

Senate Bill 598, by Senator Nancy Skinner, would remedy this situation by ensuring appropriate medical treatments and health care are provided in a timely manner.

California is not alone in recognizing prior authorization procedures have gotten out of control and are hurting patients. Thirty states have introduced nearly 90 bills aimed at reforming prior authorization. And in fact, Texas recently passed its own law to change prior authorization rules.

California is not alone in recognizing prior authorization procedures have gotten out of control and are hurting patients.

SB 598 would streamline our current prior authorization system, in which delays and denials have become an ever-increasing problem. In a recent survey conducted by the American Medical Association, 94% of physicians reported that prior authorization delayed access to necessary care for their patients.

I see it all the time in my practice— prior authorization used to be required for only expensive, elective or new procedures, but it is now required for some of the most basic prescription drugs.  And the data bears out what physicians are seeing, because while frequency rates of prior authorization denials in the commercial market remains mostly secret, we know that where we do have information – in the Medicaid and Medicare markets – the data paints a worrying picture.

A 2023 report by the Office of the Inspector General in the U.S. Department of Health and Human Services (HHS-OIG) analyzed prior authorization in Medicaid managed care programs and noted that “[p]eople of color and people with lower incomes are at increased risk of receiving low-quality health care and experiencing poor health outcomes, which makes ensuring access to care particularly critical for the Medicaid population.” In California, a majority of health plans surveyed had above-average denial rates, and one had a denial rate of 29.4%.

In a survey of the largest commercial insurance companies that participate in the Medicare program, HHS-OIG found that Medicare managed care organizations inappropriately deny medically necessary care to tens of thousands of people enrolled in private Medicare Advantage plans every year.

As a pediatrician, I see the human toll of health care delays. It is difficult to see our patients suffer needlessly because their insurance company is standing in the way of treatment. By passing Senate Bill 598, we will ensure that we don’t let corporate profits supersede patients’ health and well-being.

Eric Ball, M.D. is a pediatrician in Orange County and Vice Chair of the American Academy of Pediatrics, California.

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