Last Updated: Feb 10, 2021
HARRISBURG (February 10, 2021) – Sen. Kristin Phillips-Hill and Rep. Steven Mentzer announced yesterday the introduction of legislation that would reform the onerous prior authorization and step therapy (fail first) processes that are delaying appropriate patient care and increasingly undermining longstanding decisions made between physicians and their patients for the betterment of patient health care.
They were joined at the press conference by a number of patient and physician advocacy groups, including the Pennsylvania Medical Society who strongly supports prior authorization reform. During the virtual event, two patients shared personal stories of unreasonable prior authorization demands and fail first nightmares that led to delays in their appropriate treatment and caused serious adverse health outcomes.
Prior authorization requires physicians to obtain approval from insurers before prescribing medication, conducting tests, or moving forward with a specific appropriate treatment. It is often applied to patients living with a wide range of serious diseases and chronic conditions, including cancer, diabetes, heart disease, arthritis, and multiple sclerosis.
Step therapy requires patients to try, and fail, on one or more prescription drug, test, or treatment option at the chosen discretion of their insurance company, oftentimes without input from a physician, or input from their employed physician in a completely unrelated specialty, before gaining access to the appropriate drug, test, or treatment option that was recommended by their physician.
While insurance plans claim to use these processes to control costs, patients and medical professionals often experience delays in care and much wasted time as a result.
“What this means for patients is simple…your physicians’ hands are tied in delivering excellent care by health insurance companies,” said PAMED President Michael DellaVecchia, MD, PhD, FACS, FICS, FCPP. “We have to go through prior authorization and denials, after which the insurers tell us, as an alternative, keep the patient on their regular medication when we know that treatment has failed our patients in the past,” said Dr. DellaVecchia. “Why jeopardize their health? That unfortunately is part of the process of prior authorization.”
According to a 2019 survey of 1,000 primary care physicians and medical and surgical specialists by the American Medical Association, the negative impact of processing prior authorization requests on patients is clearly harmful to patient care. Ninety-two percent of physicians report prior authorization delays can have a negative clinical impact on patients’ care, while seventy-eight percent reported that delays can lead to patients abandoning their needed treatment altogether. Read tragic patients’ stories here.
“No two patients are the same, and what may help one patient with a particular problem may not help another,” added Dr. DellaVecchia. “Yet health insurers broadly apply the same ‘algorithms’ of generalized criteria across all spectra of individual patients when reviewing authorization requests.”
If enacted, Senate Bill 225 and House Bill 225 would curb restrictive prior authorization and step therapy (fail first) practices imposed by health insurers, as well as bring transparency and consistency to the processes of the delivery of good health care.
About the Pennsylvania Medical Society
PAMED is a physician-led, member-driven organization representing all physicians and medical students throughout the state. We advocate for physicians and their patients, educate physicians through continuing medical education, and provide expert resources and guidance to help physicians and their organizations navigate challenges in today’s ever-evolving health care system. For more information, visit www.pamedsoc.org
The press event was supported by the members ofThe Coalition to Improve Prior Authorization and Step Therapy for Pennsylvanians