Patients, doctors, insurers agree: prior approval for treatment should come

Andrew Bed, who was diagnosed with type 1 diabetes almost two decades ago, is accustomed to all the medical equipment needed to control his blood sugar. Its insulin pump has a disposable insulin cartridge and a plastic tubing system with an adhesive patch that holds the cannula that delivers insulin under its skin. He wears an uninterrupted glucose monitor on his arm.

Bade, 24, has used the same equipment for years, but every three months when he needs a new supply, he has to go through an approval process for his health insurance plan called pre-approval.

That approval can take up to three weeks, and sometimes the buddy runs out of insulin. When this happens, a resident of Fenton, Michigan, works with the remaining preloaded insulin pens. These are less specific than pumps, and he feels tired when using them. But they let him go.

“I don’t understand why they take so long to make these decisions and then they always say‘ yes ’,” Bade said.

In April, Michigan lawmakers passed a law seeking to help bed-ridden patients set standards to speed up the process. Beginning in June 2023, health plans must work on non-emergency prior approval requests within nine calendar days and emergency requests within 72 hours. In 2024, the deadline for non-emergency requests will be reduced to seven days.

“We are thrilled to have this pass,” said Dr. Nita Kulkarni, a gynecologist in Flint and a member of the board of directors of the Michigan State Medical Society. “This is a step in the right direction to reduce the waiting time for therapy.”

Michigan law is a process by state, insurers and doctors that is the latest example of an infamous attempt to sticky. Yet most initiatives have had limited success.

At least a dozen states have passed extensive reforms, according to tracking by the American Medical Association. Others have passed narrow laws that target procedures or specific types of medical services or drugs. However, state law does not protect most patients because they are in so-called self-financing plans, where employers pay direct claims instead of buying insurance for that purpose. Self-financing schemes are usually regulated by the federal government, not the states. There is no comprehensive protection at the federal level for people with commercial coverage.

A 2018 consensus statement has been slow to improve the process issued by major health plans and medical provider groups.

Prior approval requirements are intended to reduce unnecessary and inappropriate healthcare costs. Rarely will you agree with that goal. Studies have shown that about a quarter of healthcare costs are due to unnecessary, over-treatment, over-pricing, fraud and misuse, or problems with healthcare coordination and delivery.

Health plans state that prior approval requirements help protect their patients and improve the quality of care in addition to eliminating waste and defects. Doctors do not agree. They say the process often leads to delays in patient care and that delays can sometimes lead consumers to abandon treatment.

Complaints are not limited to regular commercial coverage. A report released in April by the Inspector General of the US Department of Health and Human Services examined a random sample of 250 pre-approval denials in 15 major Medicare Advantage Plans in June 2019. It found that 13% of Medicare Advantage plans had previously been denied approval. For services that meet Medicare coverage rules.

According to medical groups, the use of such requirements in health planning is increasing. According to the Medical Group Management Association, in a March survey, 79% of medical practitioners said that the requirement for prior approval increased the previous year.

While insurers and providers may agree on the merits of prior approval, many agree that the process needs to be improved. The consensus statement listed a number of areas that the group agreed to fix. For example, they say that doctors and other healthcare providers who follow evidence-based treatment guidelines and have historically high prior approval approvals may avoid the procedure.

The groups also agreed that regular review of these requirements is a good idea, with a view to excluding therapies from the list that no longer guarantee it. Improved transparency and automation also made the list.

But doctors say insurers have made little progress in the four years since the documents were released.

“It’s very bad,” said Dr. Jack Resneck Jr., a dermatologist, elected president of the American Medical Association. “We see the problem getting worse, and we don’t see health plans taking any action to honor their commitments.”

Insurers say they are working through inventory items.

“We believe that a number of concerns can be addressed through innovation in technology,” said Chris Haltmeyer, vice president of policy analysis at the Blue Cross Blue Shield Association, one of the six partners in the statement. He pointed to an electronic pre-approval pilot project adopted by the insurers trade group, AHIP, which resulted in a 69% reduction in request decision time, just under six hours.

This kind of rapid change would make a big difference for 63-year-old Jody Burke, who has rheumatoid arthritis. Burke, who lives in Bellary, Michigan, is taking expensive biological drugs to control his pain and other symptoms. A few years ago, her medication stopped working, and the pain got so bad that she could no longer take her dog for a walk.

Her doctor wrote a different biologic that she thought would treat her symptoms. But the insurer will not approve the prescribed medication unless he tries – and fails – four other medications, a pre-approval process called step therapy.

Five months before Burke was approved, he began taking a drug that effectively treated his symptoms. “With this time frame, you’re not getting any better,” Burke said. “It simply came to our notice then. There was a lot I could do and not do at the time. “

In addition to setting deadlines for working on prior approval requests, the new Michigan law sets standards for notifying physicians and other healthcare providers of changes or additions to existing requirements. And for this the insurers have to implement a standard electronic transaction process for requesting prior approval.

Dominic Pallon, executive director of the Michigan Association of Health Plan, said the standard web-based process was a key element of the law for insurers.

“Many times [providers] Submit incomplete or incorrect information, “said Pallon. “We’re trying to make it easy for the provider and get it done quickly.”

“At the end of the day, we feel like we’ve reached a good agreement,” he said.

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