As a cancer physician, the urgency of treating patients with lymphoma was brought to the forefront last year when a patient in our clinic was diagnosed with diffuse large B-cell lymphoma, a particularly aggressive form of cancer. The cancer was progressing rapidly, with one mass causing her kidneys to fail. Despite the seriousness of her condition, we knew that this type of lymphoma could be curable with a combination of immunotherapy and chemotherapy. However, our treatment plan hit a roadblock when we discovered that it required prior authorization from her insurance company, which would delay starting treatment for at least a week.
The delay caused by the prior authorization process was not something we could afford in this high-stakes situation. With the patient’s kidney function deteriorating rapidly, I had no choice but to admit her to the hospital for intravenous fluids and to initiate therapy. This unexpected hospitalization added unnecessary stress and financial burden to her cancer diagnosis, but thankfully, after five days in the hospital, she recovered well. Unfortunately, not all patients are as fortunate, with prior authorizations often leading to delays or denials of necessary medical care that can have long-term consequences.
The issue of prior authorizations has not gone unnoticed by physicians and policymakers. Efforts such as Ohio House Bill 130, sponsored by state Rep. Kevin Miller and a bipartisan group of cosponsors, aim to address the challenges faced by patients and healthcare providers in obtaining timely access to medical care. Prior authorizations require healthcare practitioners to seek approval from a patient’s insurance company before certain medications, procedures, or services can be covered. Studies have shown that prior authorizations can consume significant time for healthcare providers and result in delays or denials of evidence-based treatments.
A study published in the Journal of the American Medical Association revealed that 22% of cancer patients did not receive recommended care due to prior authorizations. Additionally, a survey of cancer physicians found that 93% believed prior authorizations could delay life-saving cancer treatment, with 31% reporting an average delay of more than five days for patient care. As insurance companies increasingly use prior authorizations to restrict or delay care, concerns have been raised by physicians, nurses, and patients about the impact of this practice.
The Ohio State Medical Association has been at the forefront of advocating for physicians and patients on prior authorization reform. House Bill 130 proposes the introduction of a ‚Prior Authorization Gold Card‘ to streamline the prior authorization process. Physicians with a high approval rate for a specific medication or service would be granted gold-card status, eliminating the need for future prior authorizations for that item. While this policy has the potential to expedite care for some patients, there are areas where the bill could be improved to have a greater impact on patient care.
One major limitation of House Bill 130 is the high bar set for qualifying for a Prior Authorization Gold Card. The current version of the bill requires 20 authorization requests for a specific service or device within a 12-month period, which may be unattainable for many healthcare providers. Additionally, the criteria for qualifying for Gold Cards for commonly used drugs, such as chemotherapy, are unclear in the updated version of the bill.
In order to enhance the impact of House Bill 130 on patient care, three key revisions are proposed:
1. Reduce the minimum number of requests required to qualify for Prior Authorization Gold Cards.
2. Clarify the criteria for Gold Cards for commonly used drugs, such as chemotherapy.
3. Implement mechanisms to bypass prior authorizations for physicians, such as automatic approval for chemotherapy regimens recommended by the National Comprehensive Cancer Network Clinical Practice Guidelines.
The authors of House Bill 130 should be commended for bringing attention to this important issue. With additional revisions and continued momentum, a final bill could help alleviate administrative burdens and improve care for patients across Ohio. It is crucial for physicians, nurses, patients, and legislators to work together to advocate for meaningful changes that prioritize patient well-being and access to timely, evidence-based care.