Courtesy of Pixabay and Myriams-Fotos

As the General Assembly nears the end of its regular session, the Kentucky Medical Association is applauding the passage of a bill that’s expected to ease the process for getting some medications and treatments preapproved by insurers.

Senate Bill 54 has been passed by both the House and Senate and awaits the signature of Gov. Matt Bevin. Its provisions include potentially speeding up the prior-authorization process for approvals to five days or less, along with other enhancements.

“Five days is a considerable improvement for our patients,” said Dr. Bruce Scott, a Louisville ear, nose and throat physician who serves as KMA president. “It’s still five days of stress and five days of waiting, but that’s a whole lot better than what we used to have, which could often stretch on for weeks.”

The bill, sponsored by Sen. Ralph Alvarado (R-Winchester), takes aim at a process that has become onerous to medical providers and patients alike, with doctors’ office staffs sometimes spending hours on hold waiting to hear back from insurers, according to KMA.

“The bill does not prevent prior authorizations from being utilized,” Alvarado said while addressing the House Banking & Insurance Committee last month. “… Instead, this legislation is meant to reform and streamline the use of prior authorizations so that this practice does not create roadblocks for patients trying to access medications and other medical treatment and does not increase health care costs or restrict health care providers from being able to do their jobs effectively.”

In recent years, both KMA and the American Medical Association have advocated for various prior-authorization issues to be addressed.

“It’s a process that physicians believe basically is a waste of resources, but more important than that, it diverts time and valuable resources away from patient care,” Scott said about prior authorization. “For patients, it delays care, it leads patients to abandon treatments that are recommended by their doctors and it adds stress to patients who are waiting for approval of a medication, a treatment, a diagnostic study that their trusted physician has recommended to them.”

A survey by the American Medical Association found that nearly 30 percent of physicians report that the prior-authorization process required by health insurers has led to serious or life-threatening events for patients. The survey of 1,000 practicing physicians also found that more than a third of physicians employ staff strictly to work on preauthorization tasks.

“Every week a medical practice completes an average of 31 prior-authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete,” AMA noted.

Stephanie Stumbo, acting executive director of the Kentucky Association of Health Plans, reminded members of the House Banking & Insurance Committee that insurance companies also have to deal with headaches related to prior authorization but that it includes protective measures to keep costs down for employers, such as small businesses that want to provide health coverage for their employees.

SB 54 would require health plans to make utilization review decisions about urgent health care services no later than 24 hours after obtaining the necessary information to do so. Decisions on non-urgent services would be made within five days of obtaining such information.

“The health plans were originally pushing for a longer period of time,” Scott said. “They pushed for seven days and the bill was originally written at 72 hours, and we compromised with five days.”

Prior authorizations for maintenance drugs – like the ones needed for treatment of chronic conditions — would be good for one year, with some exceptions, or to the end of the patient’s health plan year and cover changes in dose. Exceptions, at least some of which were lobbied for by the insurance industry, include opioid analgesics and benzodiazepines.

“It used to be that you might have to go through that (prior-authorization) process three or four times during the course of the year, even though the patient was doing well and the medication had been previously authorized by the insurance company,” Scott said. “The physician and his office would have to jump through those hoops all one more time in order to gain the approval of the insurance carrier.”

KMA President Bruce Scott speaking in favor of the bill in Frankfort. | Screenshot

Other areas addressed by the bill include requiring insurers to maintain a publicly accessible list on its website of services and codes for which preauthorization is required and making sure reviews are done by licensed physicians who are of the same or similar specialty or sub-specialty as the provider when possible. Insurers also are to develop, coordinate or adopt a process for electronically requesting and transmitting information.

In Kentucky, “we were largely still doing things — believe it or not in 2019 — with telephone on hold and fax machines,” Scott said. A staffer might “spend 45 minutes or an hour in the queue waiting to talk to a person at the health plan” and “find out this wasn’t an item on the list that needed prior authorization.”

The bill attracted support from several organizations, including the American Cancer Society Cancer Action Network.

Kristy Young, interim government relations director for the network, said the group’s interest sprang from a desire for cancer patients to get the care that they need as soon as possible instead of having to sometimes wait weeks for their cancer drugs to be authorized.

This bill “gives Kentucky patients who are undergoing cancer treatment an opportunity to get the treatment that they’ve been prescribed in a timelier fashion,” Young said. “So this could potentially improve outcomes for the patient.”