States Introduce Bills to Curb Health Insurers' Prior Authorization Practices

Core Concepts

Lawmakers in multiple states are introducing bills to address the challenges posed by health insurers' prior authorization practices and improve patient care.

Abstract

The content discusses the growing criticism of health insurers' prior authorization practices and the legislative efforts in 30 states to address these issues. It highlights the challenges faced by physicians, the federal and state-level initiatives to streamline prior authorizations, and the responses from major insurers like United HealthCare, Cigna, and Aetna CVS Health. The article also delves into the opposition from the insurance industry, the introduction of gold card legislation in various states, and the potential impact of these reforms on patient care and physician practices.

Highlights:

• Lawmakers in 30 states introduce bills to rein in health insurers' prior authorization practices.
• Federal efforts to streamline prior authorizations for Medicare patients face challenges.
• Major insurers like United HealthCare, Cigna, and Aetna CVS Health announce plans to reduce prior authorization requirements.
• States like Maryland, Washington, DC, and New Jersey propose comprehensive reform bills to address prior authorization issues.
• Gold card legislation introduced in several states aims to exempt high-performing physicians from prior authorizations.
• Challenges and limitations of prior authorization reforms are discussed, including the impact on physician eligibility for gold card status.

Stats

Last year, Congress failed to pass the Improving Seniors' Timely Access to Care Act of 2021, despite 326 co-sponsors.
United HealthCare plans to eliminate almost 20% of its prior authorizations for nonurgent surgeries and procedures starting this summer.
Cigna has removed prior authorization reviews from nearly 500 services since 2020.
California is one of about a dozen states that have introduced gold card legislation this year.
The Texas Department of Insurance estimated that only 3.3% of licensed physicians in the state have met "gold card" status since the bill became law in 2021.

Quotes

"This is something that goes on in every doctor's office every day; the frustrations, the delays, and the use of office staff time are just unbelievable." - Steven Orland, MD
"These are important reforms that will help ensure that patients can receive the care they need, when they need it." - CMA president Donaldo Hernandez, MD

Key Insights Distilled From

States Move To Curb Prior Authorization Requirements

by Christine Le... at www.medscape.com 05-26-2023

https://www.medscape.com/viewarticle/992477

Deeper Inquiries

How can the opposition from the insurance industry impact the implementation of prior authorization reforms?

The opposition from the insurance industry can significantly impact the implementation of prior authorization reforms in several ways. Firstly, insurance companies have significant lobbying power and financial resources, which they can use to influence lawmakers and policymakers against passing reform bills. This opposition can lead to delays in the legislative process or even the defeat of proposed reforms. Additionally, insurance companies may argue that prior authorizations are necessary to control costs and ensure appropriate care, creating a narrative that could sway public opinion and lawmakers. Furthermore, the insurance industry's resistance can create a barrier to transparency, making it challenging for legislators and the public to fully understand the impact of prior authorization requirements on patient care and healthcare costs.

What are the potential implications of gold card legislation on the quality and safety of healthcare services?

Gold card legislation, which exempts high-performing physicians from certain prior authorization requirements, can have both positive and negative implications on the quality and safety of healthcare services. On the positive side, gold card status can reduce administrative burden on physicians, allowing them to focus more on patient care. It can also lead to faster access to necessary treatments and procedures, potentially improving patient outcomes. However, there are concerns that gold card status may incentivize physicians to prioritize services that are easier to get approved, rather than those that are most appropriate for the patient's condition. This could potentially lead to overutilization of certain services and procedures, compromising the quality and safety of healthcare. Additionally, if the criteria for achieving gold card status are not carefully designed, it could result in disparities in care and access to services among different patient populations.

How can the challenges faced by physicians in meeting "gold card" status be addressed to improve patient care outcomes?

To address the challenges faced by physicians in meeting "gold card" status and improve patient care outcomes, several strategies can be implemented. Firstly, there needs to be clear and standardized criteria for achieving gold card status, ensuring that it reflects the quality and appropriateness of care provided by physicians. This can help prevent gaming of the system and ensure that patients receive the most appropriate treatments. Additionally, there should be mechanisms in place to monitor and evaluate the impact of gold card status on patient outcomes, including measures of quality, safety, and equity in healthcare delivery. Providing support and resources to help physicians meet the requirements for gold card status, such as education and training on evidence-based practices and quality improvement, can also be beneficial. Finally, involving physicians, patients, and other stakeholders in the design and implementation of gold card programs can help ensure that they are aligned with the goal of improving patient care outcomes.