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Prior authorization

How Prior Authorization Affects Individuals with Rheumatic Disease

April 28, 2023 | Take Action


It is important to stay up to date about health policies or plans that might impact your ability to access and afford rheumatic disease care. In this blog post, we will dive into prior authorization and cover what exactly it is, how it impacts individuals with rheumatic disease, and what is being done to reform this practice that can delay or deny necessary medical care.

What is prior authorization?

Prior authorization is a common insurance cost-control measure where physicians and other healthcare providers must obtain advance approval from a health insurance plan before the plan will agree to cover the cost of a specific service or treatment.

How exactly does prior authorization impact people with rheumatic disease?

For too many Americans, high drug prices are a barrier to effective treatments. If an insurer delays or denies coverage for a prescribed therapy during the prior authorization process, the patient may be left with the medical bill instead. Having to deal with this financial burden can force individuals to spread their treatment out longer than prescribed, delay care, abandon prescriptions, or forgo treatment entirely – all of which can increase the risk of flare-ups, disease regression, permanent disability, and even premature death. According to an analysis from IQVIA, 69% of commercially insured patients did not start a therapy when faced with out-of-pocket costs exceeding $250.

Rheumatic disease patients are particularly affected by prior authorization. According to a 2020 patient survey conducted by the ACR, 48% of patients reported being subjected to prior authorization. Another recent study of patients who receive infusion therapies for a rheumatologic condition found that prior authorization was associated with increased treatment delays and worse health outcomes.

Brooklyn Johnson
A patient shares her story

Brooklyn Johnson, a college sophomore and patient advocate, knows the dangers of prior authorization delays firsthand. Brooklyn was diagnosed with both lupus and juvenile dermatomycosis at the age of 19. In a recent interview with the Courier Journal, she explained her ongoing battle with insurance to get the treatment she needs to live a healthier and more normal college life.

“A lot of people don't see how frustrating it is when you only need insurance to see the doctor once a year," Brooklyn said. "But when you're faced with a chronic condition that lasts forever, essentially, it's really hard when insurance tries to tell you they know better than your doctor."

What is being done to fix prior authorization?

Most recently, state legislation HB 343 has been introduced in Kentucky and would implement a “Gold Card” system enabling physicians to bypass insurance prior authorization requirements for certain services after they’re able to demonstrate they consistently meet the criteria for prior authorization approval. Specifically, physicians who have a prior authorization approval rate of over 90% over a six-month period for certain services will be automatically exempt from having to submit prior authorization requests for those services.

Kentucky could become the second state in the country to enact a “Gold Card” law. Texas enacted a similar law, HB 3459, last year with broad, bipartisan support from lawmakers in both chambers of the legislature, and the backing of the patient and physician community.

Federal legislation, the Improving Seniors’ Timely Access to Care Act (H.R. 3173) has also been introduced and is currently co-sponsored by over half of the House of Representatives. ACR is urging the Energy & Commerce committee to hold a hearing on this important issue. If enacted, this law would better protect Medicare Advantage beneficiaries from prior authorization requirements that needlessly delay or deny access to medically necessary care which would create a model to enact similar protections for those under other types of plans.

And in January, the ACR released its 2022 Health Policy Statement, which outlined the College’s ongoing efforts to help improve patient access to care by urging the reduction of administrative burdens associated with prior authorization.

Have you had trouble accessing or affording treatments for rheumatic disease due to insurance prior authorization or other reasons? The ACR and Simple Tasks team want to hear from you.

Please take a few minutes to fill out our short survey. By doing so, you will be helping to advocate for better treatment access for millions of Americans with rheumatic disease.

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