States Push for Prior Authorization Reform

Robert Herman, M.D., was blunt when he testified before Maryland lawmakers: “Prior authorization of medication harms my patients and their families.”

In testimony to the Maryland Senate Finance Committee in February, he went on to outline the litany of consequences that the delay or denial of care due to prior authorization causes patients: poor work performance and job loss, suicide attempts, altercations with family members, legal problems, psychiatric hospitalization, and unnecessary suffering.

The Maryland Psychiatric Society (MPS) and Washington Psychiatric Society (WPS) this year successfully worked with lawmakers to introduce legislation in Maryland to reform the prior authorization process, as did the New Jersey Psychiatric Association (NJPA) with New Jersey lawmakers. For all three district branches (DBs), the bills represent just the beginning of their advocacy efforts around much-needed reform.

“The patients psychiatrists see often have severe disorders or impairments,” said Herman, chair of the MPS Political Action Committee. “They cannot advocate for themselves, so it is up to us as their physicians to advocate for them.”

For NJPA, advocacy around prior authorization began in 2019 when the organization began hearing more complaints from members who described the negative consequences of prior authorization, said Deb Koss, M.D., NJPA’s immediate past president, chair of the NJPA’s Council on Advocacy, and member of APA’s Council on Advocacy and Government Relations.

“We polled our members to get a better sense of the urgency of this issue, and it was clear that this rose to the top of our list of priorities for our members and their patients,” Koss said. NJPA members were sharing their experiences of having to spend an extraordinary amount of administrative time on prior authorization reviews and appeals, as well as the harm they were seeing the process inflict on patients due to delays in care.

NJPA involved the staff of APA’s Division of Government Relations to determine areas that could best be addressed via legislation, and APA developed draft legislative language for the DB. Additionally, NJPA reached out to the broader house of medicine in New Jersey and gained allies among professional organizations whose members had similar problems.

The New Jersey bill (S 1255) ensures transparency in the prior authorization process, requiring insurers to make decisions and notify the patient and physician within two business days, among other requirements. The bill was introduced in January and referred to the Assembly Health Committee.

New Jersey’s legislature meets year-round, and Koss said NJPA’s advocacy on the issue will continue. NJPA is working with the bill’s sponsors to expand the legislation and include language eliminating prior authorization in many instances, including for generic medications and dosage changes and after a patient has been on a medication for at least six months.

WPS had been hearing about “the overwhelming administrative burden and the patient horror stories related to prior authorization” from its members for some time, said Steve Israel, M.D., president of WPS. WPS and MPS collaborate on a joint legislative action committee, and given the interest from both organizations, they set out to work with APA staff to draft legislative language and find a sponsor to introduce legislation in Maryland.

“One thing we learned in the process is that neither the legislators nor the Maryland Insurance Administration seemed to have a good idea of the extent of the problem,” Israel said. “Education played a big role.”

The Maryland bill (SB 688) would have eliminated prior authorization for generic medications, dosage changes, and both generic and brand name drugs after the patient has been on these medications for six months without interruption. It would also have required that insurers respond to appeals within 48 hours and that denial reviews be conducted by physicians of the same or similar specialty as the physician whose recommended treatment is under review. The bill stalled in committee, but both Herman and Israel expressed high hopes for the effort moving forward.

“I get the feeling this will be a long process, but it will be worth it in the end,” Israel said. “It will take effort to rally support among the public and convince legislators that action needs to be taken.”

APA’s state team is also working with the Prior Authorization Work Group to develop model legislation that other DBs can use in their own states to implement prior authorization reform. As the work in Maryland and New Jersey exemplifies, many of the prior authorization problems that psychiatrists experience are universal. There appears to be momentum for prior authorization reform across the country—almost half of the states have introduced such legislation this year, and a sweeping reform law is now in effect in Michigan. APA and the work group will be taking all this legislation into consideration when developing model legislation for DBs, said Erin Berry Philp, APA’s director of state government relations.

“When we organize as a group of physicians, we can be so much more effective than any one of us acting alone,” Koss said. “Our district branches, with support from APA staff, are a natural place for us to come together and organize for state-level advocacy.” ■