Medical professionals in Michigan are urging lawmakers to change the state's prior authorization laws. Authorization is an insurance requirement by which doctors need to receive prior approval for services or medications before a patient's insurer will cover them.
Insurers say authorization helps to control medical costs and protects patients from questionable procedures, tests, and medications. But doctors and patients disagree.
How does prior authorization impact medical care?
requires patients in Michigan to go through a series of steps before they can receive certain medical tests, procedures, and medications. The goal of prior authorization is to protect patients from medical malpractice and negligence while also protecting insurance companies from potential lawsuits.
For instance, the statute of limitations in states like Alabama is two years
for wrongful death claims and personal injury. If a doctor recommends that a patient use a new medical device (polyurethanes, which are made using reaction injection molding
, are often used in medical device applications) and the application goes wrong, the patient could potentially file a lawsuit. Prior authorization could reduce the risk of situations like this from happening.
But doctors and patients say the prior authorization process isn't efficient.
Lyndsey Crosbie, 33, said in an interview with Bridge
that her insurance initially denied her coverage for a prescription of Celebrex, which Crosbie takes for her endometriosis. Endometriosis
is just one of the many chronic conditions six out of every 10
baby boomers are expected to be living with by 2030.
Crosbie was instructed to try six less expensive medications first before taking Celebrex. This is a process known as step therapy. However, Crosbie's doctor had prescribed her Celebrex specifically to sidestep Crosbie's allergic reactions to other medications.
"Every single option [on the step therapy list], I'm allergic to it," said Crosbie. "I'm like 'Did you guys even pay attention'?"
Crosbie isn't the only one frustrated by the prior authorization process. Dr. Bobby Mukkamala, the president-elect for the Michigan State Medical Society, says the prior authorization process can endanger lives because it delays medical care for patients, second-guesses doctors' medical expertise, and eats up staff time.
"By the time patients come to me, they've been on five courses of antibiotics," said Dr. Mukkamala. While the next step for patients would be to undergo a CT scan to search for blockages and tumors, Dr. Mukkamala says these scans are put on hold while patients and doctors wait for insurance companies to give them the go-ahead.
"This is something that comes up in my office no less than five times a day," Dr. Mukkamala said.
What is the legislation being proposed?
The legislation proposed by Senator Curt VanderWall, R-Ludington, chairman of the Health Policy and Human Services Committee, would require insurers to respond to a doctor's request within 24 hours in urgent matters and within 48 hours in non-urgent matters.
Insurers would also be required to base their decisions on consultations with doctors and specialists and to post their prior authorization policies on their websites.