Doctors call on legislature to tackle prior authorization

The Connecticut State Medical Society is taking aim at the health insurance industry's practice of prior authorization this legislative session. Prior authorization, also known as "precertification" or "prior approval" is an insurance industry cost-control process where health care providers must obtain advance approval from an insurance plan before care is provided.

In a video press conference Thursday, representatives of the Connecticut State Medical Society decried prior authorization as burdensome and disruptive for patients and caregivers alike.

"Originally prior authorization started for major procedures, like cardiac surgery or cancer treatments," said Dr. Bob Russo, chief medical officer of CSMS. "Now it's all across the board and there's no uniformity to it [the process of prior authorization]"

Russo said that, in his experience, patients frequently experienced problems in getting necessary medications due to prior authorization issues. For patients who take medications long term, insurance companies demand that prior authorizations be renewed periodically.

"We've had to maybe do two-to three prior authorizations a month to 10 to 15 prior authorizations a day for a primary care practice," said Russo. "They've expanded it to where the burden is overwhelming for the practice."

A 2021 American Medical Association survey of physicians found that 88 percent of doctors found the process of prior to be administratively burdensome. That same survey found 93 percent patients who were made to use prior authorization experienced some delay of care.

In some cases these delays can be problematic. An article from the biomedical news site STAT outlines a case of a woman with fast-spreading cancer who was delayed by prior authorization issues for 38 days, resulting in multiple amputations.

"Yesterday it took me on the phone waiting for 40 minutes on hold while my patient is waiting disrobed for her procedure in an exam room," said CSMS president Dr. David Hass. He explained that his patient has been having problems swallowing for over 6 months and that a procedure to open her esophagus had repeatedly been denied for prior authorization issues. "It was all because someone wasn't reading the forms properly at the insurance company."

Another point of contention for the doctors were prior authorization requirements that demanded patients try several medications before getting the one prescribed by their doctor, a process known as step therapy. This was particularly an issue for Hass's patients with Crohn's disease. It's also a common problem in migraine care.

According to the doctors, prior authorization can also delay discharge from a hospital to a long-term care facility or nursing home.

"There's no ability on the part of our hospitals to get prior authorization on a weekend," said Dr. David Emmel, chair of CSMS's legislative committee. "They have to hold patients at enormous expense to the hospital, wait until Monday, and then get prior authorization. That's entirely preventable."

Representatives of CSMS said that they hoped that Senate Bill 6 would help address these issues by including language to reduce the burden prior authorization pose to doctors and patients. They hoped for bipartisan consensus for tacking this issue.

"We've proposed a number of solutions that the state can pursue," said Emmel. He outlined programs that had worked in other states, like unified standards for insurance providers, 24/7 prior authorization processing, and an end to step therapy. "We are asking the legislature to move forward with this as part of Connecticut's package."