Minnesota legislation targets health insurers' power to block medical care, medications [Star Tribune]

Health insurance companies would lose power over patients in Minnesota if lawmakers approve limits on the use of prior authorization for treatments and medications.

The House voted to prevent prior authorization reviews of many treatments for cancer and mental disorders, and eliminate redundant reviews for chronically ill people with unchanged treatment needs. The Senate so far has favored a smaller package of reforms. Both chambers would extend existing limits on prior authorization reviews to the state's Medical Assistance and MinnesotaCare programs.

Rep. Kristin Bahner, DFL-Maple Grove, said she has been fighting for years to enact these limits. She used to work in a prior authorization unit for an insurance company and coached people to get through the process because she thought it was cumbersome and stacked against them.

One elderly man had to fight for cream for toenail fungus, she recalled. "I just remember all of the hoops he had to jump through. I was like, 'You know, if this was my grandfather, would I want him to have to navigate these really difficult and complex waters in order to get something so simple?'"

Prior authorization is practically a four-letter word when it comes to public opinion and the way it can disrupt care that doctors recommend. A recent national survey found that 16% of all insured adults had experienced problems with the review process.

But it's also one tool that limits wasteful or unnecessary medical spending, keeping health insurance premiums from rising even faster.

A leader of Minnesota's health insurance industry said he supports the expansion of prior authorization deadlines to state programs, including the five-day limit on standard reviews. But Lucas Nesse, chief executive of the Minnesota Council of Health Plans, said he fears that other proposed limits could inflate costs for patients. Broad limits on treatments of chronic diseases could be particularly expensive, when considering the frequency of these conditions, he said. One in 10 Minnesotans has diabetes and three in 10 have hypertension, according to a state health dashboard.

"Prior authorization is an extremely important process," he said, and double-checks doctors to make sure prescriptions won't interact harmfully with other drugs and patients have access to the most affordable treatments.

In the end, most reviews support doctor recommendations. Blue Cross and Blue Shield of Minnesota approved 76% of the 136,294 treatments it reviewed last year, according to its annual report, which was required by legislative action in 2020. When patients appealed denials, more than half were overturned.

To Bahner, an approval rate that high suggests a futile process. Doctors shouldn't be spending multiple hours every week on paperwork if insurers are going to back them anyway, she said, and insurers shouldn't be asking patients to justify treatments for chronic diseases if their needs haven't changed.

"We're delaying care, necessary care, and sometimes in really critical situations," she said.

A conference committee of House and Senate lawmakers will likely decide, before Monday's end of the session, which prior authorization limits to recommend for final votes. The six-person panel includes three DFL lawmakers who have championed prior authorization reforms, but they will balance them against other priorities in this year's catch-all health budget bill.

Lawmakers also want to limit how hospitals collect medical debts, provide payment boosts to help independent pharmacies survive, and expand access to mental health care. They also are eyeing penalties for hospitals if they fail to issue public notices of unit closures or substantial reductions in their operations.

The DFL-led House voted 68 to 59 last week in favor of prior authorization reforms, at a state cost of $32 million in 2026 and 2027. Minnesota's fee-for-service Medical Assistance program, which provides health benefits for low-income and disabled residents, denies 40% of claims for outpatient substance abuse and mental health care services. Use of those services could increase 67% without prior authorization reviews and result in more state spending, according to a fiscal analysis.

Nesse said he believes the analysis underestimates the cost of scaling back prior authorization.

Doctors and hospital leaders endorsed the proposals, which would relieve administrative burdens on providers that have been under financial pressure since the COVID-19 pandemic. Patients shouldn't be forced to review insulin if current versions are keeping their diabetes in check, or justify treatments "over and over again" for irreversible conditions such as cerebral palsy, said Mary Krinkie, vice president of government relations for the Minnesota Hospital Association.

"What are you saving vs. the harassment factor?" she said. "There's a balance."

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