Prior authorization is a requirement to have the insurer approve a treatment before they will cover it. While prior authorization may have a role for services for which a treatment is questionable or where services may be overutilized, its overuse delays needed care, adds to administrative costs, and results in a net cost to population health. Growing prior authorization burdens are also a leading driver of physician burnout.
Why are insurers requiring 75-90% of physicians who are providing the correct care to “jump through hoops” when the required prior authorizations are ultimately approved (based on the data reported by Minnesota’s top five insurers). National data shows that physicians complete on average of 41 prior authorizations per week and that they or their staff spend more than 13 hours a week on getting prior authorization approvals.
While those numbers are shocking, what is worse is the impact prior authorization is having on patient care. According to research, 94% of physicians report that prior authorization has led to care delays, 80% report that prior authorization can and has led to treatment abandonment by patients, and 33% report that prior authorization has led to a serious adverse event for their patients, including 19% reporting that it has been a life-threatening event, or one intended to prevent a permanent impairment.
Current Minnesota law prohibits the use of prior authorization for emergency services. That law should be expanded to prohibit prior authorization for other services that are too important to create barriers. These services include medications to treat a substance use disorder, outpatient mental health and substance use disorder treatment, treatments to fight cancer consistent with national cancer-care guidelines, generic drugs deemed therapeutically equivalent by the FDA, preventive services recommended by the U.S. Preventive Services Task Force, pediatric hospice services and neonatal abstinence programs, and treatments covered through value-based arrangements.
Additionally, legislation should limit the use of prior authorization for chronic conditions to one-time only approvals, and require insurers to annually report to the Commerce Department how often they use prior authorization, how often they deny services and how often they approve services. Finally, the the Minnesota Commissioner of Commerce shall develop a “gold card” program for physicians with prior authorization approval rates above the 70th percentile.
Electronic Prior Authorization (ePA)