WILMINGTON -- As policymakers continue to seek ways to cut health care costs and reduce the deficit, they are faced with the challenging task of decreasing spending without jeopardizing the quality of care received by patients. As daunting as this may seem, there is significant potential not only to reduce medical costs but to improve patient access to care, simply by reforming outdated and inefficient insurance company protocols.
Our North Carolina-based organization represents thousands of practicing rheumatologists across the country who have to deal with these policies on a near-daily basis. Two protocols in particular - prior authorization and step therapy - are responsible for driving up costs and interfering with physicians' ability to provide effective treatment.
Prior authorization refers to an insurance company policy that requires doctors to obtain the insurer's approval before it will agree to cover the cost of certain treatments. To meet prior authorization requirements, doctors and their staffs often have to complete a time-consuming series of faxes, phone calls, emails and input of data into insurance carrier Web sites.
In other words, prior authorization creates a bureaucratic mess for physicians that distracts from patient care and drives up medical costs for everyone. Worse, patients are often forced to wait days or weeks for insurers to approve treatments. In many cases, medications or procedures are simply denied.
Insurance carriers also use step therapy, or "fail-first" protocols, which require that one or more less costly medications "fail" to help a patient before the carrier will agree to cover a more expensive option, even if a physician believes it's the best option for that patient.
Currently, both prior authorization and fail-first protocols are primarily paper-based and extremely inefficient. This onerous amount of paperwork costs a national average of $83,000 per physician each year, according to a recent Health Affairs study. An American Medical Association survey found that physicians can spend up to 20 hours per week on average just dealing with pre-authorization requests, and an earlier study in Health Affairs estimated that the total costs to physicians can reach $23.2 to $31 billion a year.
These insurer protocols not only place a heavy burden on medical providers, they unnecessarily delay treatment for rheumatology patients already struggling with chronic pain.
We recently conducted a nationwide survey of our member rheumatologists and discovered that dissatisfaction with health insurer protocols is nearly universal. Nearly 99 percent of rheumatologists surveyed reported that they have had to alter treatment plans, including changing prescription medications to accommodate restrictions imposed by health insurance carriers, and 91.5 percent of survey respondents said prior authorization has a "negative" to "very negative" effect on their ability to treat patients.
Rheumatology encompasses chronic diseases such as osteoarthritis, rheumatoid arthritis, carpal tunnel syndrome, osteoporosis and other pain disorders. While these diseases cannot be completely cured, the immense pain and suffering of patients can be reduced through specially tailored treatment by a rheumatologist.
This specialized care is essential not only in reducing the severity of the disease and preventing disability but in saving time and reducing costs. Increasingly, however, insurance protocols like prior authorization and step therapy are causing detrimental delays and preventing rheumatologists from providing their patients with the most appropriate and effective methods of treatment.
There are a number of steps that state legislators and insurance commissioners can take to help rheumatologists and other physicians bypass insurance barriers and provide the care their patients desperately need.
First, policymakers can require that all insurers use a short, standardized form for prior authorization requests to reduce the confusion, costs and delays caused by time-consuming paperwork.
Officials can also make it easier for physicians to adopt electronic prescribing systems, which can streamline the prior authorization process and reduce dangerous and unnecessary delays in treatment.
For their part, insurers can reduce unnecessary delays by setting up a peer-to-peer system of communication that helps providers to quickly resolve prior authorization issues with their counterparts at the insurance carrier.
Finally, insurers must be required to resolve prior authorization requests within a reasonable time frame, because making the system more efficient won't help patients get the care they need if carriers aren't required to make prompt decisions.
Chronic diseases like osteoporosis and rheumatoid arthritis cannot be cured, but with specialized medical care from a physician, they can be treated. While rheumatologists are doing all they can to ease their patients' pain, oftentimes their hands are tied by health insurance protocols. It is up to state legislatures and insurance commissioners to act to ensure that patients with chronic rheumatic diseases do not needlessly suffer any longer.
Michael Schweitz. M.D., is president of the Coalition of State Rheumatology Organizations, headquartered in Wilmington.
