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HARRISBURG — Chronically ill patients may find it easier to get their insurance companies to approve new treatments under a bill that Pennsylvania lawmakers are rushing to pass in the final days of the legislative session.
The 67 pages The bill, which usually applies to private insurers, would revoke pre-approval for emergency care, standardize timelines for insurers to approve or deny a request for treatment, and guarantee that doctors can request that plans cover medications without that a patient first tries a cheaper drug.
Proponents say the bill will allow medical providers to spend more time on care rather than fighting with insurance companies, and give patients greater clarity and flexibility in deciding their treatment options.
But changes to a subject as complicated as the state insurance law, even when a bill is backed by two parties, can quickly become messy — and poking the needle between a number of well-heeled lobbies has prevented similar changes for more than a decade.
Industry groups for insurers, hospitals and physicians all have strong lobbying in the Capitol. The Insurance Federation of Pennsylvania, in particular, spends millions of dollars annually to influence lawmakers.
“It’s a big bill. Details count,” said Sam Marshall, CEO of the federation. He did not specify what concerns he had with the bill, but said “all parties are working together in good faith”.
The bill has the support of more than 70 condition-specific organizations, including those representing diabetes, arthritis and multiple sclerosis patients, among other chronic conditions. They argue that the bill will give patients faster access to health care.
At the heart of the proposal is an effort to change two key components of the US health care system: pre-authorization and step therapy.
Pre-approval gives an insurance company the authority to decide whether a medical procedure or treatment is medically necessary before deciding to cover it. Step therapy is a specific form of prior authorization for medicines, whereby an insurer, such as a cost-saving measureasks a patient to try one drug and see evidence that it doesn’t work before approving the patient’s preferred treatment.
The bill would not completely eliminate both practices. It would instead require insurers to offer waivers for both, and create a standardized process for doctors to apply for approval or request a waiver, and for patients to appeal an insurance company’s decision.
It would do this by creating standardized electronic forms to request approval, establishing a legal timeline for responding to requests (72 hours for urgent requests and 14 days for non-emergency services), requiring written notice from insurers explaining the refusal, and providing the State Insurance Department the opportunity to review the decision.
The bill would also allow doctors to challenge an insurer’s decision directly with a physician employed by the insurer — a process known as peer-to-peer review — rather than someone who may not have a medical degree.
All in all, “this creates a new and more effective pre-approval process for medical services, and it keeps everything consistent and transparent from start to finish,” said Senator Kristin Phillips-Hill (R., York), the sponsor of the bill. .
Private insurers defend their discretion as a necessary cost containment method to keep insurance rates low. But advocates for patients and health care providers argue that these administrative steps favor insurance companies and reduce their ability to make important health care decisions.
“It would be like having a pipe burst in your house and being told not to call a plumber and try to mop first,” Mark Lopatin, a retired rheumatologist from outside of Philadelphia, told Spotlight PA. Lopatin sits on the board of the Pennsylvania Medical Society, which supports the bill.
He’s seen patients switch insurers and be asked to forgo a drug they’d been taking for years because the new plan wouldn’t cover their medication until they tried a cheaper alternative. The bill would specifically allow an exemption for step therapy in such a situation.
Lopatin’s experience is not unique. A 2021 American Medical Society questionnaire of the 1,000 physicians across the country reported that 93% experienced care delays due to prior authorization, and 82% said those delays led patients to discontinue treatment.
“Scientific breakthroughs [and] medical advances mean that in many cases a diagnosis can now be managed and treated,” said Emma Watson, the chief lobbyist for the state branch of the American Cancer Society and the liaison for the other patient groups. “Patients need the ability to quickly manage their condition. assess with their medical professionals to find the best course of action for their individual health needs.”
In some cases, the bill would only bring the state insurance law, last rewritten in 1998, into line with federal law. The proposed ban on prior authorization for emergency care, for example, corresponds to a federal law passed at the end of 2020. However, medical providers have since challenged that law in court.
Changes to the state insurance law have been considered for years, but have never reached the governor’s office.
The current proposal was passed unanimously in June by the state’s Republican-controlled Senate, but “once it got in the House, there were a lot of people who were concerned,” said House Insurance Committee Chair Tina Pickett (R. ., Susquehanna) recently.
Her committee approved an amendment on September 20 that preserved many important provisions. Watson of the patient coalition still supports the bill; Marshall of the insurance federation said he is still reviewing the changes.
Pickett said she expects more talks with stakeholders before the bill can be finalized.
Both Governor Tom Wolf, a Democrat, and House Speaker Bryan Cutler (R., Lancaster) have expressed interest in seeing through changes to pre-approval in the final days of the two-year session.
In an email, Wolf spokesperson Beth Rementer said ensuring patients receive timely medical services is a “critical part of ensuring patients’ access to quality health care,” and that concerns are at the heart of talks about the bill.
The bill now awaits a ground vote in the state house and the state senate must approve the changes before the measure can reach Wolf’s desk.
The House still has three session days before the end of the year; the Senate, which must approve the lower chamber’s edits, has six.
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