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Getting involved in PA reform

Medical Economics JournalMedical Economics May 2024
Volume 101
Issue 5

Prior authorization reform: ©Piter2121 -

Prior authorization reform: ©Piter2121 -

Physicians looking for ideas about prior authorization (PA) reform have various resources to choose from.

A good place to start could be the American Medical Association, which has model legislation with 14 pages of definitions and rules that would streamline the process.

Megan Srinivas, M.D., M.P.H., is an infectious disease specialist practicing in Iowa. In 2022, she was elected to the Iowa House of Representatives, where she has been living the lessons of legislation to reform PA in that state.

In February 2024, the bill House File 2488 was introduced to establish the following:

  • 48-hour response time for urgent requests for PAs
  • 10 days for nonurgent requests
  • 15 days for cases with complex or unique circumstances or in periods of unusually high volume of PA requests.

There would be an annual review for PA necessity and elimination for those without cost savings. There would be a PA exemption pilot program in which all health insurers would be required to create pilot programs starting in 2025 to exempt some participating health care providers, including primary care physicians, from prior authorizations. Reports back on results would be due in January 2026.

The Iowa Medical Society (IMS) and Wellmark Blue Cross Blue Shield, the largest private payer in the state, drafted the legislation. Srinivas and Kady Reese, MPH, CPHQ, policy and government relations director of IMS, offered their advice on how physicians could better understand the legislative process and connect with lawmakers in their own states.

Share your stories

Physicians have knowledge about patients that legislators don’t have, but that they need to have.

“They don’t just need the numbers, but they need the humanity of what you’re seeing every day, whether it’s the 5-year-old that couldn’t get the care they needed because of the prior auth process, or this 85-year-old,” Srinivas said. “The humanity you put into the legislative process by sharing your stories with us, creates better outcomes.”

Make the time for contacts

Srinivas knows her fellow physicians are busy, making it tough to take on other tasks.

“But if you can show up to testify, if you can email one of your legislators, if you can reach out in any way and just be a resource that they can trust, you can actually affect grander change that’s both for your immediate patients, but also in perpetuity for the system overall,” Srinivas said. “And that’s what we need. We need knowledgeable voices at the table that put the humanity back into the legislation.”

Legislation needs a goal with real results

“At the end of the day, the most important thing to us is not just a policy that pushes paper,” Reese said. “If it doesn’t actually improve how our physicians are able to practice and how our patients are able to experience care, it’s not a win for us, even if it looks good on paper.”

Consider patient care as common ground with insurance companies

“A lot of times, we always kind of see insurers as the bad guy, as the opposition,” Reese said. PA has a role in certain circumstances, and neither physicians’ offices, hospitals or insurance companies have enough staff to go handle every request.

“So we wanted to sit down with them and say, we know that this is a stickler issue, we’re coming to the table under the best of intentions of saying, we all want the best care for patients, we all want the most economical care for patients. How can we do that?” Reese said.

For example, starting in October, toward the end of the year, people start spending down on their health insurance plans, which leads to more requests for insurance companies. The payers don’t want to staff year-round for the busiest times, which is understandable, so that led to the 15-day response time during times of high requests, or for complex cases that require considerable review, Reese said.

Work in the off season

In Iowa, the legislative session traditionally runs from January to April. The IMS, state lawmakers and insurance representatives prepared for that by meeting and drafting the legislation before the legislators reconvened. When the legislation was introduced on Feb. 13, 2024, it passed unanimously in committee and then in the Iowa House on Feb. 29.

Prior authorization reform is gaining bipartisan support

“The fact that it passed unanimously through its subcommittee, the committee, and when it came to the House floor debate is pretty compelling,” Reese said. “There was no arm twisting, there was no argument. It didn’t require heavy and impassioned testimony because this is a commonsense solution to a widespread issue that’s affecting every patient, every physician. This isn’t just a special interest issue, this is about Iowans.”

Politics takes time

The legislative process exists to ensure checks and balances, and politics plays a part in that process. Even if people agree on a problem, they may not agree on the solution. Once Srinivas’ bill went to the Iowa Senate, it returned to the House with an amendment that requires additional consideration.

“When you have a bill like ours that was universally supported, it can become a very attractive vehicle to attach other things to,” Reese said. “So that’s another piece that plays into this, that sometimes benefits us and sometimes delays that process, which is very, very frustrating.”

This article was edited to reflect the Iowa Medical Society's involvement in drafting House File 2488.

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