Texas is reining in prior authorization that harms patients. Congress should, too

If you want to know why physicians in Texas fought so hard to pass new legislation to roll back insurance company red tape, read my patient’s story.

This patient suffers from a neurological condition. When his symptoms flare, it becomes impossible for him to read, drive, work, or eat. When the symptoms start, he calls me, and I begin a three- to four-week ordering process through the insurance company to get approval for the medicine that calms his muscle spasms.

By the time the medication arrives, his condition is so far out of control, it will take a week for him to regain his life. Even though I have treated him for two years with the same medication, the insurance company forces us to endure this bureaucratic nightmare every time his symptoms strike.

My patient isn’t the only one harmed by insurance companies delaying access to care. Each year, millions of Americans find themselves in a similar holding pattern for health care as insurance companies force doctors to get approval for the treatments they prescribe.

This process, called prior authorization, can create dangerous and unnecessary care delays, saddles physicians with mountains of paperwork and diverts precious time and resources that should be devoted to patient care.

Texas is trailblazing a path to rein in prior authorization. The Legislature approved House a measure, taking effect Sept. 1, that will allow doctors to bypass prior authorization if 90 percent of their medical orders were approved by the insurance company in the previous six months.

This so-called “gold card” law will reduce red tape. More importantly, it will help ensure patients across Texas get the care they need in a timely manner.

I hope Texas’ landmark law inspires nationwide reform. This is an issue that affects all Americans. According to a recent survey by the American Medical Association, a whopping 90 percent of physicians said that prior authorization harmed patients’ health, while 94 percent reported treatment delays due to the practice.

Meanwhile, federal data show that three-quarters of all Medicare Advantage plan requests denied under prior authorization were eventually approved, suggesting there was no reason to delay care for most patients.

The most recent and egregious example of this problem is a policy implemented by Aetna that requires prior authorization for all cataract surgeries, whether the patients are children born with cataracts, adults struggling to drive or read through cloudy vision, or someone who needs emergency surgery. Aetna, the nation’s third-largest health insurer, provided no reason for creating a policy that no other large healthcare insurer believes necessary. Though they may be the first, I fear they may not be the last.

Sens. Ted Cruz and John Cornyn should build on the reforms we’ve passed in Texas and support national legislation to make prior authorization more efficient and transparent. Congress is considering the bipartisan Improving Seniors’ Timely Access to Care Act of 2021, legislation that would improve the prior authorization process by requiring Medicare Advantage plans to implement electronic processes to speed approvals, increase accountability, and ensure beneficiary protection standards are being met.

Now is the time for nationwide reform. Our patients can’t wait any longer.