By Monalisa Tailor, M.D. and Rep. Kim Moser
When you’re trying to manage a health condition and your physician has prescribed a treatment or medication, you shouldn’t have to wonder if your health plan will cover it—or if you’ll have to wait days or even weeks for an answer. Unfortunately, that’s the case for many Kentuckians whose insurers have implemented burdensome and unnecessary prior authorization requirements. If you have diabetes, COPD, asthma or migraines, you are likely no stranger to this phenomenon.
When you go in to see your doctor and you decide on a plan of care, they may order a medication or imaging study for you. However, before it can be done, your insurer may require a prior authorization. Prior authorization is a complicated, time-consuming process that requires physicians to obtain advance approval from a health plan before their patient can access a specific service or medication. Prior authorizations have become a major barrier in our healthcare system, leading to potentially dangerous delays for patients, administrative burdens for physicians and increased costs.
Prior auth reform has been a priority for the Kentucky Medical Association (KMA) for years—and we’re continuing to call for legislation that will make it easier for patients to get the treatments they need, when they need them, while giving back valuable time to physicians.
Rep. Kim Moser and Dr. Monalisa Tailor
Physicians chose a career in medicine because they care deeply about serving and helping others. We want to spend more time engaging with patients and less time talking on the phone with insurance companies, completing cumbersome prior authorization paperwork and pleading for our patients to get the treatment we know they need.
House Bill 134, sponsored by Rep. Kim Moser, proposes a solution to this persistent problem. The legislation would create a prior authorization exemption program that automatically waives prior auth requirements if a physician has historically been approved for a specific procedure or service most of the time (e.g., 90 percent). A prior authorization exemption program would ensure Kentuckians have timely access to the care they need, while reducing administrative burdens for physicians and allowing our healthcare system to operate more efficiently.
When physicians see hundreds of patients per week and need to complete numerous prior authorization forms, the time and costs add up quickly. Researchers estimate waste in the healthcare system, including administrative costs like prior authorization, amounts to $245 billion, or $2,497 per person, per year.
Furthermore, a 2021 American Medical Association survey of more than one thousand practicing physicians nationwide revealed that over 40 percent have staff who work exclusively on prior auth, and on average, process 41 prior authorizations, per physician, per week. Each required prior authorization costs physicians between $10.92 and $14 to obtain.
Simply put, prior auth is consuming valuable time and resources that would be much better spent on caring for patients—and it’s also putting their health and wellbeing at risk.
In a recent member survey conducted by the KMA, more than 80 percent of physicians said that issues related to the prior auth process led to delays or changes to their patients’ recommended course of treatment. When prior authorizations force Kentuckians to wait for their treatment or medication, we run the risk of them abandoning their physician’s recommendations altogether.
The lengthy prior auth process not only impacts patient behavior and outcomes; it affects physicians, too. Seven in 10 physicians who responded to KMA’s survey said that the amount of work associated with the prior auth process has increased in recent years, pulling them away from their patients and leading to burnout.
There are simple things we can do to streamline our increasingly complicated healthcare system and ensure patients are receiving the right care, at the right time. Implementing the prior auth exemption program laid out in House Bill 134 is one of them.
Rather than allowing insurance companies to dictate when, where and how Kentuckians receive care, we should leave those decisions to physicians and their patients who have trusted them with their health and wellbeing. The steps we take to reform prior auth will help us to put patients first — and that’s what healthcare is really about.
Monalisa Tailor, M.D., is an internal medicine physician in Louisville and President of the Kentucky Medical Association. Kim Moser serves as State Representative of the 64th District and is the sponsor of House Bill 134.
