Improving how we deliver healthcare in Idaho

Navigating your health insurance can get complicated fast once you move beyond deductibles and co-pays. Prior authorization, a utilization-management tool, is one of those complications. It was originally created to help insurance providers deal with high-cost, high-risk or unusual healthcare services. Prior authorization should support appropriate care, not become an obstacle to care.

Over time, its use has expanded dramatically into routine and recurring care. I understand why insurance companies needed this tool. Not every procedure works equally well in every situation. But patients shouldn’t be caught between their doctors and these companies.

In practice, improving the process means healthcare decisions come from the provider-patient relationship. Insurance companies can review and provide a safeguard against potential abuse rather than overriding reasonable medical judgment. You and your family bear the consequences when a management tool delays medically necessary treatment.

We’ve also heard repeated requests from patients for greater transparency to improve the healthcare marketplace. Patients and providers should know what requires prior authorization, what criteria are being used, and why requests are denied. Rules should be publicly available, understandable and consistently applied. Transparency improves trust and allows competition to work more effectively.

Then, there’s the time factor. Delayed care eventually becomes denied care. Prior authorization decisions should happen within predictable timeframes. Multiple requests for additional information that wasn’t required in the first place, and repeated administrative cycles create real-world consequences for patients. Urgent cases deserve urgent responses.

Once a patient and provider supply the necessary proof of medical need, patients shouldn’t need to reverify the same chronic condition every few weeks or months, unless the medical protocol indicates a patient should have completed treatment. The prior authorization process should provide meaningful certainty so patients can schedule procedures and continue treatment without fear that approvals will disappear unexpectedly.

This tool was created for a valid purpose. But over time, its use has expanded to medical care that people are told their insurance plans cover. We won’t solve the cost issues associated with healthcare by forcing patients to jump through more administrative hoops for services they’ve paid to receive every time they make a premium payment.

I know Idaho can lead the way on reforming this process to support patients and providers, while respecting the business needs of insurance providers. But the status quo can’t continue. Prior authorization can’t remain the metaphorical hammer for every healthcare nail that pops up. We can and should do better to improve how we deliver healthcare in our great state.