Preserve patient-provider relationship

The relationship between patients and their health care providers is the cornerstone of America’s medical system, one built on the trust that prescribed treatments and medications lead to healing and improved quality of life for the patient.

Unfortunately, as we see in Pennsylvania and across the nation, the more stakeholders who interfere with this relationship, the more that foundation is eroded.

We see this perhaps most immediately in prior authorization and step therapy policies.

Health insurance providers are implementing these practices at an increased rate, creating potentially harmful results for patients who have serious chronic diseases.

The intents behind these practices are, on the surface, understandable.

Prior authorizations — in which the insurer determines if a prescribed drug is medically necessary, appropriate for the patient and follows clinical guidelines before approving coverage — ideally help manage costs and better align care to best practices.

Meanwhile, step therapy, also known as “fail first,” requires patients to try and fail on a certain drug or a series of drugs, which may be cheaper, before approving the originally prescribed medication.

However, the actual execution of these practices by insurers proves there are severe inefficiencies, which can lead to long delays or recklessly deny the proper medications.

For example, physicians and their staff spend an inordinate amount of time securing authorizations for their patients.

This is because many prior authorizations are performed manually — mostly via phone calls, mail, fax or email — or on partially electronic systems, such as web portals, rather than through more efficient fully electronic systems (HIPPA mandates these, but the adoption rate by insurers is low).

According to a 2020 study, providers spend an average of 20 minutes on a single manual authorization, compared to eight minutes on a fully electronic transaction, and the process adds hundreds of millions to health care costs annually.

After submission, the process may be just beginning for patients, who can wait days or even weeks for approval. A December 2020 study by the American Medical Association found that 94% of the 1,000 practicing physicians surveyed reported patient care delays caused by prior authorization.

In addition, 79% reported patients abandoning treatment altogether because of the practice’s trouble and 30% reported patients suffering a “serious adverse event” due to it.

Concerning step therapy, the potential risks are more overt.

Insurers often base their decisions on poor evidence of efficacy or cost, forcing patients to return to prior ineffective medications, or forcing stable patients to change medications after formulary changes, while being inflexible in the policy’s implementation.

The frustration that comes from knowing a certain medication will alleviate a patient’s symptoms, but the insurer insisting on trying another drug is immensely frustrating for the physician.

Now just imagine how trying it is for the patient. All too often in medicine, there is no time to fail first.

With the past year proving how vital timely, readily accessible care is to patient outcomes, Pennsylvania’s General Assembly can help preserve the provider-patient relationship.

Committees in the House and Senate are considering matching bills that aim to create a quicker, more efficient prior authorization system, including a mandated electronic process.

The legislation also provides a clearer, clinically based route to step therapy exemptions.

These bills must be a priority for lawmakers. Even as we emerge from the greatest public health crisis of our generation, many threats to patients remain.

We cannot fail them.

Dr. Ralph D. McKibbin is a gastroenterologist based in Altoona.


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