May. 22, 2019

By Rep. Steven Mentzer
Prior authorization is a requirement that physicians obtain approval from insurers before moving forward with a specific treatment, performing a test such as an MRI or prescribing medication. While this may not sound like a difficult issue, in fact it is. When you are sick or in pain, not having a well-defined prior authorization procedure can create additional healthcare problems. 

Another issue, similar to prior authorization, is “step therapy”. This is where an insurance company requires patients to try, and fail, on one or more prescription drug or treatment options chosen by their insurance company before gaining access to the drug, test, or treatment option that was originally recommended by their physician.

Here are just a few examples of how these systems, when inefficient, delay care:

• The Pittsburgh Post-Gazette featured a man from Indiana County (Pa.) whose insurance company delayed approval of an MRI after he tore his rotator cuff in a fall – a decision that delayed treatment by 16 weeks and may have done lasting damage to his shoulder.

    • In another example, a teenager from Middletown received delayed care for his juvenile idiopathic arthritis. His mother wrote in PennLive about the persistence she needed to finally get approval, calling her insurance providers every business day for nearly a month. The day it was approved, the mother took the day off from work and stayed on the phone for three hours.

    Insurance plans say they use these processes to control health care costs and I applaud all efforts to keep these costs under control. That being said, I say that controlling costs should not have to come at the expense of patient care. Unfortunately, there are signs that it is: more than one in four doctors said delays from prior authorization have led to serious adverse events for their patients, according to a survey from the American Medical Association.


    I have put forth commonsense reforms to these systems through the introduction of House Bill 1194. They are designed to improve these systems – not discard them – so that prior authorization and step therapy can work better for everyone.


    It will ensure that patients and health care professionals can access a more efficient electronic prior authorization system. It sets deadlines for how long an insurer can take to respond to a prior authorization request.


    It also establishes a basic framework for when it is medically appropriate to exempt patients from step therapy.


    House Bill 1194 has the backing of the American Cancer Society’s Cancer Action Network, the Pennsylvania Medical Society, and The Hospital and Healthsystem Association of Pennsylvania.


    My hope is that it will allow you to access the care you need without costly delays and potentially harmful impacts.


    Lancaster County resident Steven Mentzer represents the 97th District in the Pennsylvania House of Representatives.