Christopher Marks noticed an immediate improvement in his symptoms when his doctor prescribed Munjaro, a type 2 diabetes drug, last year.
A 40-year-old truck driver from Kansas City, Missouri, said his average blood sugar levels have dropped significantly and he is taking less insulin than before to keep his blood sugar levels within target range. But when Marks' doctor followed a typical prescribing pattern and increased his dose of Munjaro, a drug with a wholesale list price of more than $1,000 a month, Marks' health insurance company refused to pay for the drug.
Ms. Marks had Cigna insurance purchased through the Federal Health Insurance Marketplace, healthcare.gov. After a month and a half and two appeals, Cigna agreed to cover the higher doses.
A few months later, when it came time to increase his dose again, he said he was denied it again. By November, he decided it was no longer worth sparring with Cigna, as the insurance company exited the Missouri market earlier this year. He decided to continue on the lower dose until his new insurance covered him.
“It's very frustrating. People shouldn't have to think, 'It's not worth fighting to get treatment,'” Marks says.
The process Marks encountered is called “preauthorization,” or sometimes “preauthorization,” and claims insurers use it to control costs and protect patients from unnecessary or ineffective care. are doing. But this practice goes beyond patients like Marks, who argue that prior authorization can impede treatment, cause burnout among health care workers, and increase administrative costs. The move has drawn backlash from groups representing medical professionals and hospitals.
The Biden administration announced new rules in January to streamline the process for patients with certain health plans, after attempts in Congress stalled, including a bill passed by the House in 2022. But states are considering preclearance laws that go even further.
Last year, lawmakers in 29 states and Washington, D.C., considered about 90 bills restricting prior authorization requirements, with notable victories in New Jersey and Washington, D.C., according to the American Medical Association. The medical association expects to introduce more bills this year, many of them enshrined in a model bill the group drafted.
In 2018, health insurers signed a consensus statement with various medical facilities and provider groups that set out a wide range of areas to improve the prior authorization process. But the lack of progress since then shows the need for legislative action, said former AMA president and current trustee Jack Resneck Jr.
“They haven't delivered on their promises,” Resneck said.
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Resneck, a California dermatologist, said pending bills in Indiana, Massachusetts, North Carolina, Oklahoma and Wyoming include speeding up response times and requiring insurers to publicly report pre-authorization decisions. , highlighted that it includes several policies supported by the AMA, such as insurance premium reduction programs. amount of requests. Also known as “gold carding.” The bill has been introduced by both Democratic and Republican lawmakers, and some, like Colorado's, are bipartisan.
In Missouri, a bill introduced by Republican Rep. Melanie Stinnett (R-Springfield) aims to establish a gold card system for treatments and prescriptions. Stinnett said that until he entered Congress in 2023, he was regularly frustrated by preclearance hurdles in his work as a speech therapist.
“The stories are all similar. It's a big battle to get something done on the insurance side to get it approved,” Stinnett said. “Then even after all the battles, you can feel like it might not have been worth it because some people change their insurance in the new year.”
His bill would review health care providers' prior authorization requests during a six-month evaluation period. After this period, providers whose requests are at least 90% approved are exempt from the obligation to submit requests for the next six months. The exemption also applies to facilities that meet the criteria. And they would still have to meet the criteria to maintain the “luxury” of exemption, she said.
Five states have passed some form of gold card program: Louisiana, Michigan, Texas, Vermont, and West Virginia. AMA tracks active gold card bills in 13 states, including Missouri.
A 2022 survey of 26 health insurance plans conducted by industry group AHIP found that just over half of them use gold card programs for medical services, and about one-fifth use gold card programs for prescriptions. It turned out that it was. They gave mixed reviews, with 23% saying patient safety improved or remained the same and 20% saying the practice increased costs without improving quality.
New federal prior authorization rules finalized by the Centers for Medicare and Medicaid Services stop short of gold carding and do not address preauthorization for prescription drugs like Marks' Munjaro prescription.
Starting in 2026, new rules will establish response time frames and public reporting requirements for some insurers participating in federal programs such as Medicare Advantage and the Health Insurance Marketplace, and will eventually introduce electronic processes. will be required. According to the 2022 Insurance Survey, manual submissions accounted for 39% of preauthorization requests for prescriptions and 60% of preauthorization requests for medical services.
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In Missouri, state and national organizations representing doctors, nurses, social workers, hospitals and others support Stinnett's bill. Opposition to the plan comes primarily from pharmacy benefit managers and the insurance industry, including the company Marks handled the preauthorization process for last year. Cigna Healthcare executives submitted testimony that the company's experience showed that the Gold Card policy “results in inadequate care and increased costs.”
The St. Louis Regional Business Health Coalition, which represents dozens of employers with employee health insurance, also opposes the bill. Members of the coalition include financial services company Edward Jones, coal company Peabody Energy and airline giant Boeing, as well as several public school districts and the St. Louis city and county government.
Louise Probst, the coalition's executive director, said the pre-authorization process is problematic, but the coalition would prefer a solution from insurance companies and health care providers rather than new state laws.
“The reason I don't like to see things freeze is because you lose flexibility and nuance that could be helpful to patients,” Probst says.
On the other side of the state, Marks bought this year's insurance on the federal market from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed a higher dose of Munjaro, which Cigna refused to cover. About a week later, Marks said, his new insurance approved the higher dose “without any fuss.”
Cigna spokesman Justin Sessions said the company uses prior approvals for popular drugs such as Munjaro to ensure patients receive the right drug and dose.
“While we strive to ensure that approvals are made quickly and accurately, in Mr Marks’ case we fell short and we deeply regret the stress and frustration this has caused,” she said. Stated. “We are reviewing this matter and identifying opportunities for improvement to prevent this from happening in the future.”
Marks' purpose in using this high dose of Munjaro is to wean off other diabetes medications. He specifically wants to stop taking insulin, which requires multiple injections a day and carries the risk of dangerous complications from hypoglycemia.
“I don't really use the word 'life-changing,' but in a sense it is,” Marks said. “It would be great if I could get off insulin.”
This story was first published KFF Health News.
