News & Media
Health Can’t Wait: Patients and Providers Ask Legislature to Limit Health Care Delays, Insurance Company Red Tape
Physicians and health care providers today joined with patients and patient advocates asking the state Legislature to approve a new package of bills that would reform prior authorization and step therapy practices—policies insurance companies use to slow—and sometimes deny—care and treatment to Michigan patients.
Senate Bill 612, sponsored by Curt VanderWall, Chair of the Senate Health Policy and Human Services committee, introduces new transparency and clinical validity requirements that would protect Michigan patients from costly and dangerous delays in access to health care.
Step therapy is an insurance company protocol that purportedly limits insurer expenses by forcing patients to try less effective, lower-cost treatments and medicines and “fail first” to see improved health, before insurers will cover the medicine or treatment prescribed by a patient’s physician or health care provider. Patients and physicians report frequent adverse health consequences caused by the insurance company policy that keeps them from the treatment they need.
Prior authorization is a burdensome regulation used by health plans to prevent patients from accessing the medicine they’re prescribed until insurers first check doctors’ orders with insurance company formularies. It’s a process that often leads to delays and denials of care for Michigan patients.
“Following through with the fail first protocol my insurance company wanted to follow probably would have put me in the hospital again,” said Lyndsey Crosbie, a patient from Dearborn with a severe allergy to NSAIDs who was told by her insurance company that she would need to fail first on several NSAIDs before they would cover the safe, NSAID-free alternative prescribed by her doctor. “I’m hoping my story resonates with our state lawmakers because patients around Michigan need this reform. Our health can’t wait.”
Under the legislation, physicians would be empowered to override step therapy protocols when they consider it not to be in a patient’s best interest. The act would also require insurers to base their prior authorization requirements on clinical, evidence-based criteria established with input from practicing physicians.
“Prior authorization, step therapy and fail first requirements aren’t just a hassle for patients—they threaten their health,” said S. Bobby Mukkamala, MD, president-elect of the Michigan State Medical Society. “This red tape costs Michigan patients their time, health, quality of life and sometimes even their lives.”
The Health Can’t Wait Act of 2019 would also establish the following in regard to prior authorization and step therapy:
- Transparency – Insurance company prior authorization requirements will be published on the insurer’s website in detail and in easily understandable language.
- Clinical validity – Adverse determinations and decisions on appeals must be made by a physician in the same specialty as the service being requested. Medical directors of insurance companies must be licensed to practice medicine
- Fairness for patients – Urgent and non-urgent prior authorization requests must be acted upon within 24 and 48 hours, respectively.
According to a 2018 survey of physicians conducted by the American Medical Association (AMA), 28 percent of physicians report the prior authorization process had led to at least one serious adverse event such as death, hospitalization, disability, or permanent bodily damage to a patient in their care, with 75 percent reporting that prior authorization issues can lead to treatment abandonment.
“Prior authorization and step therapy practices are needlessly jeopardizing the health and well-being of patients around Michigan every single day—that’s all anyone should need to hear to know that reform is necessary,” said Trudy Ender, executive director of the Susan G. Komen Foundation of Michigan.
Recent research suggests the problem is growing. 88 percent of physicians report that prior authorizations burdens have increased over the last five years.
“The biggest costs associated with these insurance company burdens are the effect they have on patients’ health,” said practice management consultant Kathy Jo Uecker. “Henry Ford Health System alone has 100 full-time staffers devoted to processing these prior authorization request. That’s all time and resources that could be better devoted to patient care.”