Last Updated: Apr 30, 2019
For Immediate Release:
HARRISBURG (April 30, 2019) – State Rep. Steven Mentzer and a coalition of patient/provider advocates announced Tuesday legislation that would reform insurance tactics that are delaying care and increasingly undermining decisions made between health care professionals and their patients.
House Bill 1194 addresses inefficiencies within insurance processes called prior authorization and step therapy (“fail first”).
Prior authorization requires physicians to obtain approval from insurers before prescribing medication or moving forward with a specific test or treatment. Step therapy requires patients to try, and fail, on one or more prescription drug, test, or treatment option chosen by their insurance company before gaining access to the drug, test, or treatment option that was recommended by their physician.
Prior authorization and step therapy are often applied to patients living with a wide range of diseases and chronic conditions, including, but not limited to, cancer, diabetes, HIV/AIDS, heart disease, arthritis, and multiple sclerosis.
Insurance plans use these processes to control health costs, but opponents say their current use delays care. More than one out of four physicians reported delays from prior authorization
have led to serious adverse events for their patients, according to a February 2019 nationwide survey from the American Medical Association.
“When you are sick or in pain, time is of the essence. And yet many Pennsylvanians are not currently receiving the timely care they need because of prior authorization and fail first,” said Rep. Mentzer, a Republican from Lancaster County. “The solutions presented in House Bill 1194 will ensure patients receive more timely care, allow insurers to be more transparent, and reduce administrative burdens for physicians and their office staff.”
Representatives from the American Cancer Society Cancer Action Network (ACS CAN), the Pennsylvania Medical Society (PAMED), The Hospital and Healthsystem Association of Pennsylvania (HAP), the Pennsylvania Chapter of the American College of Cardiology (PaACC), and the Pennsylvania Orthopaedic Society joined Rep. Mentzer at a press conference Tuesday in the Capitol Rotunda.
“Scientific breakthroughs mean that, in many cases, a cancer diagnosis can now be managed and treated,” said Emma Watson, ACS CAN Pennsylvania government relations director. “Patients need the ability to quickly assess their condition with their doctors and find the best course of treatment for their individual medical needs.”
House Bill 1194 does the following:
- Ensures physicians and other prescribers have access to more efficient electronic prior authorization systems (“ePA”)
- Requires that fail first protocols are based on clinical guidelines developed by independent experts
- Establishes a basic framework for when it is medically appropriate to exempt patients from fail first, as well as an exceptions process that is transparent and accessible to patients and health care professionals
- Provides deadlines for insurers to render decisions on prior authorization requests
“Many of my physician colleagues say prior auth is taking too much time away from what they do best – using their many years of training and experience to care for patients,” said Danae Powers, MD, president of PAMED. “We are grateful to Rep. Mentzer for the commonsense solutions he presents in HB 1194. They will cut down on inefficiencies in this system and help patients get the timely care they deserve.”
“Ensuring that Pennsylvania’s patients can get the treatments they need to get better is at the heart of the hospital community’s mission,” said Andy Carter, president and chief executive officer of HAP. “We have heard countless stories about the barriers that patients and their providers encounter, which prevent timely and appropriate care. Thanks to Rep. Mentzer’s leadership, we have a reasonable set of reforms to remove these barriers and improve patient outcomes.”
Marc Kaplan, American Cancer Society Cancer Action Network
Jeff Wirick, Pennsylvania Medical Society
Rachel A. Moore, The Hospital and Healthsystem Association of Pennsylvania
About the American Cancer Society Cancer Action Network
The American Cancer Society Cancer Action Network (ACS CAN) is making cancer a top priority for public officials and candidates at the federal, state and local levels. ACS CAN empowers advocates across the country to make their voices heard and influence evidence-based public policy change as well as legislative and regulatory solutions that will reduce the cancer burden. As the American Cancer Society’s nonprofit, nonpartisan advocacy affiliate, ACS CAN is critical to the fight for a world without cancer. For more information, visit www.fightcancer.org
About the Pennsylvania Medical Society
The Pennsylvania Medical Society helps its 21,000 physician and medical student members return to the art of medicine through advocacy and education. To learn more, visit www.pamedsoc.org
or follow us on Twitter at @PAMEDSociety.
About The Hospital and Healthsystem Association of Pennsylvania
HAP is a statewide membership services association that represents nearly 240 organizations, as well as the patients and communities they serve. Additional information about HAP is available online at www.haponline.org