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Washington and New Jersey Are Reforming Prior Authorization. Is Your State Next?

Broad grassroots support can make a big difference

Nearly 1 in 3 adultsopens in a new tab or window will be diagnosed with depression in their lifetimes — often marked by a nearly out-of-body level of disorientation. We lose our ability to think clearly, to emote normally — even our very sense of selves.

Picture this: Your patient is already grappling with this life-changing experience and struggling to make it to health appointments, when they are denied needed medical care. A patient with a mood disorder suddenly had her decades-long stable medication denied because her diagnostic category changed, and it was now not considered first line. She had to pay thousands out of pocket or change medications at a sensitive time and risk a relapse.

Over 1 in 4 (26%)opens in a new tab or window of insured people with mental health conditions have had insurance companies block access to therapy or prescription medications via prior authorizations — making it even harder to get better, or stay well.

As you’ve likely experienced with your patients, health insurance companies can require pre-approval for clinical treatments or services before covering their costs — we know this practice all too well as prior authorization. While intended to curtail unnecessary care, in reality, this process makes it harder to access, and even blocks, recommended care.

Luckily, in New Jersey and Washington state, there have been recent legislative pushes to reform this process — along with at least 80 prior authorization bills underway in 28 other statesopens in a new tab or window with a lot of promise.

Prior authorizations increase profitsopens in a new tab or window for insurance companiesopens in a new tab or window, while harming both patients and clinicians. Nationally, 31% of physiciansopens in a new tab or window report that these criteria are rarely or never evidence-based, while another 43% say they are only sometimes so, according to the American Medical Association (AMA).

As physicians and public health leaders, we have directly witnessed these impacts.

The AMA also found that 94% of clinicians who reported prior authorizations have delayed care. Nearly half (46%) say they’ve led to urgent or emergency care, and a quarter (25%) report that they’ve led to a patient being hospitalized. Nearly 1 in 5 (19%) report the process led to a life-threatening event, while almost 1 in 10 (9%) report that it led to permanent disability or death — all preventable outcomes.

On top of all this, clinical teams spend nearly 2 full business days (14 hours) per week completing prior authorizations — burdening clinicians who are already experiencing epidemic levels of burnoutopens in a new tab or window.

We are thrilled that for the first time, we’ve seen record activity at the state level in the last several months to reform all this, with many other states with bills in progress. AMA President Jesse Ehrenfeld, MD, MPH, noted, “We’re pretty optimistic about the rest of this legislative year,” with respect to these bills to unblock needed medical care and improve patient outcomes.

Washington passed a bill in 2023 that went into effect this year (2024) that establishes:

  • Faster turnaround times for prior authorization approvals, ranging from 1-5 days
  • Automation of prior authorization systems into electronic medical records
  • Increased transparency

New Jersey’s billopens in a new tab or window, passed last month — which will go into effect in January 2025 — goes even further.

Starting in 2025, New Jersey insurance companies will need to share detailed data around prior authorizations, such as number of denials and reasons. Peer-to-peer conversations will need to happen for denials, with a physician from the same specialty or with recent experience with that treatment. And turnaround times for prior authorization for medications will be reduced from 15 days to 24 hours for urgent requests, as defined by the treating clinician.

At the federal level, a rule was finalized in January 2024 by CMS that will require greater transparencyopens in a new tab or window on denials, electronic integration, and responses for urgent prior authorizations within 72 hours for Medicare Advantage, state Medicaid, and Medicaid managed care plans. These requirements will go into effect in 2027, but will not affect commercial plans.

We believe momentum is building to eliminate these unnecessary roadblocks to needed healthcare once and for all — and that many other states are primed to follow suit.

In New Jersey and Washington, broad grassroots support from clinicians and patients were pivotal in moving legislation forward.

When we spoke with New Jersey Assemblyman Herb Conaway, Jr., MD, a physician and bill co-sponsor, he attributed the state’s legislative success on this issue to combined efforts from organized medicine, the legislature, and grassroots advocacy. “If you’re trying to knock a wall over, you start with shovels and pitchforks,” he said of the grassroots efforts. “You bring people in the front and in the back — pushing and pushing and pushing — until the wall falls over.”

We all hope this grassroots framework similarly helps compel change in other states.

If you have a story about how prior authorizations have harmed a patient, yourself, or a family member, please write to your representatives at this critical moment — or use this AMA formopens in a new tab or window to help move the needle nationally. It could make a critical difference at this watershed moment. We’d love to see more ready and equitable access to needed healthcare across the country, and for clinicians to do their jobs without blockages imposed by insurance companies.

Devika Bhushan, MD,opens in a new tab or window is a pediatrician and public health leader focused on resilience and equity; she leads a transformative well-being communityopens in a new tab or windowTina Shah, MD, MPH,opens in a new tab or window is a pulmonary and critical care doctor in New Jersey and Chief Clinical Officer of Abridge.

 

Read More at MedPage Today.