CSRO survey explores impact of health insurance barriers

The Coalition of State Rheumatology OrganizationsOct 1 2011

The Coalition of State Rheumatology Organizations (CSRO) today released the findings of a nationwide survey that explored the impact of health insurance barriers such as prior authorization and step therapy on the ability of rheumatologists to provide effective care to patients. The survey revealed a broad dissatisfaction with health insurance protocols and the ways in which they impact the ability of physicians to treat patients.

"Rheumatologists around the country have increasingly voiced their concerns about the impact of health insurance protocols such as prior authorization and step therapy on patient care," said Reuben Allen, CSRO Executive Director. "These practices are stripping rheumatologists of the ability to direct the most appropriate and effective courses of treatment, which causes patients to suffer delays or outright denials of proper medical care. Individualized treatment plans that can restore, enhance, and preserve quality-of-life over time are essential to rheumatology patients and their struggle against autoimmune and destructive arthritic disorders."

Specific findings of the CSRO survey include:

• Nearly 99% of rheumatologists surveyed say they have had to alter treatment plans including changing prescription medications to accommodate restrictions imposed by patient health insurance carriers;

• 91.5% of survey respondents say prior authorization has a "negative" to "very negative" effect on their ability to treat patients;

• Nearly 97% of rheumatologists surveyed agree, "There should be enforceable legislation to regulate restrictions that insurance companies place on health care providers in regards to treatment modalities they prescribe for their patients;"

• Nearly 98% of survey respondents agree that decisions about what medications are best for a patient should be made by the patient's own health care provider and not by the health plan or  insurance company;

• Nearly 73% of respondents say they are only "sometimes" or "rarely" able to easily determine what procedures will be covered by a patient's health plan at point-of-service;

• 52.2% of rheumatologists surveyed say they have considered re-establishing their practices as fee-for-service only because of prior authorization constraints.

Prior authorization, also known as pre-authorization, pre-certification or prior notification, is an extra set of steps some insurance carriers require before determining whether they will pay for a medical service or prescription medication. The physician, or other medical provider, is required to obtain approval from the insurance carrier before the carrier will agree to cover the cost of the medical service or prescription medication. Step therapy, also referred to as "fail-first," requires patients to "fail' on one or more less costly medications before the health insurance carrier will agree to cover a more expensive medication, even if a physician thinks it is a better option for the patient.

Currently, prior authorization and fail-first protocols are primarily paper-based, and non-standardized. Each insurance carrier has its own set of requirements, which can vary among plans, even within the same carrier's portfolio of coverage options. To meet prior authorization requirements physicians must complete a time-consuming series of faxes, phone calls, emails, input of data into insurance carrier web sites and, in some cases, letters.  

In response to the survey, CSRO also announced its recommendations to policymakers in addressing prior authorization protocols by ensuring that:

• Prior authorization should be standardized and improvements in the current process can be made by the adoption of a universal prior authorization form;

• Electronic prescribing platforms are provided on neutral and open platforms that do not advance the commercial interests of any particular participant (e.g., health insurers, hospitals, pharmacy benefits managers, pharmaceutical companies, etc.) to the potential detriment of the patient;

• Adjudication of prior authorization requests occurs within a reasonable time frame (hours as opposed to days or weeks); and communication between physicians and payers should be on a peer to peer basis;

• Electronic prescribing platforms include access to information about all FDA-approved medications and medical services without restrictions;

• Complete, up-to-date information about prior authorization and fail-first criteria is available through electronic prescribing platforms at point-of-service;

• Prior authorizations should not be required on a repeated basis. It should only be necessary with a change in medication dictated by a change in clinical status;

• Prior authorization should not be necessary for low cost medications; for example, prednisone and methotrexate.

Many rheumatologic diseases are very serious and complex. They can be difficult to diagnose and treat and many can change or evolve over time. Specialized care from a rheumatologist is essential in order to reduce the severity of disease and prevent disability, as well as to save time and to reduce costs. Delaying the specific treatment needed for rheumatology patients by forcing them to endure fail-first protocols is detrimental to the patient's physical recovery as well as their psychological well-being.

"Physicians are responsible for the administrative costs associated with meeting prior authorization and fail first requirements. These include direct costs to cover staff time, and hidden costs, such as time and resources diverted from individual patient care," explained Allen. "Prompt diagnosis and specially tailored treatment can improve the long-term outcomes of patients with rheumatologic diseases. State legislatures and insurance commissioners should take appropriate steps to ensure that patients suffering from chronic rheumatic diseases and chronic pain do not have to needlessly suffer."