I'm a doctor: Here's how Kentucky can reform medical prior authorization with HB 343 – Courier Journal

Every doctor in America has written a letter similar to this at some point in their career:

Dear Claims Administrator,

I am writing to request authorization for [MEDICATION] for my patient, [PATIENT NAME], who has been diagnosed with [DIAGNOSIS] and I believe that treatment with [MEDICATION] is appropriate and medically necessary. Attached to this request is a detailed medical history…

My fellow rheumatologists and I are all too familiar with this arduous process – spending precious hours each week writing letters to insurance companies seeking approval for the prescriptions our patients need to effectively manage their complex conditions. 

This process, known as “prior authorization,” is used by health insurance companies to control plan members’ access to specific treatments and services —usually as a cost-saving measure. But there is no uniformity in the prior authorization requirements between different insurers, so doctors must manually fill out multi-page forms for each patient who needs a treatment requiring prior authorization. Further, most insurance plans require an annual review — meaning another round of paperwork — and if a patient switches insurance plans during treatment, they and their doctor often must start the process all over again. And when you consider the fact that the vast majority of prior authorization requests – including nearly 100% of my practice’s requests for generic medications – are ultimately approved, it raises questions about what purpose these policies actually serve.

According to a recent national survey from the American Medical Association, 93% of physicians said prior authorization had resulted in delayed care. Even more frightening is the fact that 34% of physicians – one in three – reported that prior authorization has led to a serious adverse event, such as hospitalization, permanent disability, and even death, for a patient under their care.

The 1 in 4 Americans living with rheumatic disease are particularly affected by prior authorization. According to a 2020 patient survey conducted by the American College of Rheumatology, 48% of patients reported being subjected to prior authorization.

Moreover, a recent study of patients who receive infusion therapies for a rheumatologic condition found that prior authorization was associated with increased treatment delays and worse health outcomes. Delaying care by merely a few weeks can be the difference between successful treatment or permanent joint damage and disability. 

So, you can imagine my relief when I learned that Kentucky lawmakers are considering House Bill 343 that would significantly reform the prior authorization process by implementing what is known as a “gold card’ system. Under this system, physicians who have a prior authorization approval rate of over 90% over a six-month period for certain services will be automatically exempt – or “gold carded” – from having to submit prior authorization requests for those services. The legislation would allow doctors who consistently meet prior authorization requirements to bypass this arduous process and prevent state-regulated insurance companies from delaying their patients’ care.

Additionally, insurers would still be able to conduct periodic reviews to ensure system integrity.

If passed, Kentucky will be the second state to implement a “gold card” system for prior authorization. A similar law was enacted in Texas last year with broad, bipartisan support from lawmakers, patients and physicians in the state.

Kentuckians should not have to wait for medically necessary care because their doctors have been forced to spend hours chasing down approvals for needed treatments.  It’s time for Kentucky policymakers to step up and take action to fix a process sorely in need of reform.

Dr. Chris Phillips is a practicing rheumatologist in Paducah, Kentucky and former chair of the American College of Rheumatology’s Insurance Subcommittee.  

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