Time For Congress To Solve The Prior Authorization Problem For All Americans

The unanimous passage of the Improving Seniors’ Timely Access to Care Act in the U.S. House is an important victory in the ongoing fight to curb insurance company abuses that delay or outright deny medically necessary care for patients in need. The entire patient community is glad to see lawmakers support this much-needed legislation, which will help streamline and simplify the delivery and coordination of care for seniors and persons with disabilities enrolled in Medicare Advantage.

But there’s still work to be done.

The bipartisan Improving Seniors’ Access to Timely Care Act aims to overhaul the prior authorization process – one of insurers’ most widespread and flagrant abuses – and protect Medicare Advantage beneficiaries from having to jump through hoops simply to access the care they need and that their doctor prescribed. The legislation would modernize the outdated process by requiring the use of electronic prior authorization tools, which would speed up approvals. This is crucial since 93% of doctors say prior authorization leads to delays in treatment, and 34% say it has led to a serious adverse event for a patient in their care. By preventing dangerous delays, the legislation – along with a complementary rule recently proposed by the federal government – would help ensure seniors and patients with disabilities can access prescribed treatments and services when they need them.

While its passage in the Senate would mark a major milestone and victory for patients, the legislation applies only to the roughly 30 million Americans covered by Medicare Advantage; it does not change anything for patients in traditional Medicare, Medicaid, or those who are covered by private insurance.

Absent federal action in these other areas, lawmakers at the state level are pressing forward on several prior authorization reforms to ensure the timely delivery of care. Pennsylvania Gov. Tom Wolf recently signed a bill to streamline the process by requiring insurers to provide timely coverage decisions for both emergency and non-urgent care to physicians before treatments and services are rendered.

In signing his state’s prior authorization bill into law, Wolf joins a bipartisan handful of other states – from deep red Texas to true blue Michigan and Illinois – attempting to solve this problem. However, the limited progress in the states has been through slow and often hard-fought legislative efforts. Unfortunately, that leaves patients in the vast majority of states subject to the whim of insurance providers looking for any reason to delay or deny paying for needed care.

For example, some Medicare Advantage patients in Florida and Georgia still face additional hurdles in accessing care by insurers requiring prior authorization for sight-restoring cataract surgeries, despite it being a safe, routine procedure that is the only treatment for a common affliction. Patients with rheumatic disease are also particularly impacted by prior authorization, with an American College of Rheumatology survey finding that 48% of patients report being subjected to the cumbersome process. Increasing treatment delays and worsening patient outcomes can leave many patients struggling to live their everyday lives.

Recent findings by the American Society for Clinical Oncology (ASCO) and the American Hospital Association (AHA) report similar trends. An ASCO survey primarily of medical oncology professionals found that nearly all participants report having a patient that experienced harm from the prior authorization process. Most widely cited were delays in treatment (96%), patients being forced into a second-choice therapy (93%), or patients being denied therapy (87%). Even more disturbingly, 80% report disease progression and 36% report loss of life. When the time to act on cancer treatment is so precious, this additional burden is literally life or death.

Similarly, the AHA found that nearly 80% of hospitals believe relations with commercial insurers are getting worse, due in large part to the proliferation of prior authorization requests, which are taking increasingly more time and staff resources than ever. Not only does prior authorization take time away from physicians that should be spent with patients, but it also can put their patients in danger as the report makes clear, citing several particularly egregious examples. This is clearly an issue impacting patients across the spectrum of our healthcare system and putting the well-being of Americans in jeopardy – all due to ill-advised insurance policies that clearly do not prioritize the health of patients.

While we celebrate the House’s passage of the Improving Seniors’ Timely Access to Care Act and the Biden administration’s recent proposed rule on prior authorization, we urge senators to champion the cause and pass this popular bipartisan reform. Lawmakers in both chambers should build on this momentum and extend protections beyond Medicare Advantage so all patients may get the medically necessary care they need to live fuller, healthier lives.

Terry Wilcox is the cofounder and CEO of Patients Rising, a patient organization that provides programs and services ranging from education, navigation, and self-advocacy to policy solutions.