As an oncologist, I was reminded last year that lymphoma can be treated without waiting for insurance company approval.
One of our patients was diagnosed with a malignant tumor, Diffuse Large B-cell Lymphoma. The lymphoma was growing rapidly and one of the tumors was causing kidney failure. This was an extremely dangerous situation, as Diffuse Large B-cell Lymphoma is often curable with a combination of immunotherapy and traditional chemotherapy.
We knew her diagnosis and the treatment that would most likely cure her, but there was a problem: After submitting a treatment plan to her insurance company, we learned that, like many cancer treatments, it would be subject to a prior authorization (PA) process that would delay the start of treatment by at least a week.
While waiting for the insurance company's decision, her kidney function rapidly deteriorated, so I had to rush her into the hospital and start her on IV fluids and therapy. This added an expensive and emotionally painful hospital stay to her cancer diagnosis, but thankfully she recovered well after five days in hospital. Some patients are not so lucky and suffer long-term harm when their PA delays or denies them necessary medical care.
Thankfully, doctors and policymakers are beginning to take notice of the issue, and proposals such as Ohio Bill 130, introduced by Ohio Representative Kevin Miller and a bipartisan group of cosponsors, aim to improve timely access to health care.
Prior authorization (PA) is an insurance practice in which a health care provider obtains approval for a drug, procedure, or service from a patient's insurance company before the insurer will cover it. PAs have been shown to waste a lot of time for doctors and nurses and can delay or deny evidence-based treatment. A 2023 study in the Journal of the American Medical Association showed that 22% of cancer patients did not receive the treatment recommended by their doctor because of PAs. Furthermore, in a survey of cancer doctors, 93% said PAs could delay life-saving cancer treatments, and 31% said the average delay in patient care was more than five days.
As insurance companies increasingly use PAs to obstruct or delay medical care, doctors, nurses and patients have raised concerns about the practice, and the Ohio Medical Association has taken a leading role in advocating for doctors and patients on PA reform.
House Bill 130 is the first effort to address these concerns. The bill proposes a “pre-authorization gold card” to make PAs more efficient. Physicians with high approval rates for certain drugs or services could earn gold card status, eliminating the need for future PAs for that item. If structured properly, this policy could reduce wait times for treatment for some patients.
However, we want to highlight areas where HB 130 can be improved to enhance its impact on patient care.
The 2023 draft bill and the revised version set high hurdles for gold card eligibility. The latest version requires 20 approval applications for a particular service or device within a 12-month period. In addition, the revised bill is unclear as to whether and how commonly used drugs such as chemotherapy would qualify for the gold card.
The number of claims required is a major constraint on the bill’s potential to improve patient care: It is rare for a single physician to order a drug, service, or procedure 20 times in a 12-month period.
While the inclusion of provider groups in the update is a welcome change, this barrier remains insurmountable for most services in smaller clinics and hospitals.This distinction is important.
In 2021, the Texas Medical Association successfully lobbied to reduce the six-month billing minimum requirement from 20 to five. Despite this adjustment to Texas law, in the first two years after it was passed, only 3% of doctors and other health care professionals received a gold card for any services.
We call on doctors, nurses, patients, and lawmakers to support House Bill 130’s three important amendments.
Reduce the minimum number of requests to qualify for a pre-authorization Gold Card. Clarify Gold Card criteria for commonly used medications, such as chemotherapy. Plan other mechanisms to bypass physician pre-authorization, such as automatic approval of chemotherapy regimens recommended in the National Comprehensive Cancer Network Clinical Practice Guidelines.
The authors of House Bill 130 should be commended for shedding light on an often-ignored issue, and with further revisions and continued promotion, we are hopeful that the final bill will reduce administrative burdens and improve health care across Ohio.
Michael Lamonica is a medical student at the University of Cincinnati. Brian Hambly, MD, MPH is a Hematology Oncology and Bone Marrow Transplant Physician at the University of Cincinnati College of Medicine. The opinions expressed here are those of Mr. Lamonica and Dr. Hambly and not of their institutions or employers.
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