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House of Representatives
Session of 2021 - 2022 Regular Session


Posted: January 19, 2021 12:41 PM
From: Representative Steven C. Mentzer
To: All House members
Subject: Prior Authorization (Prior House Bill 1194 – 19/20 Session)
We all know that administrative waste in the healthcare delivery system is significant. We have all, at one time or another, experienced our healthcare provider recommending a course of treatment or medication “pending the approval of your health insurance company.” This approval process is commonly referred to as prior authorization, or PA.

As you might expect, PA is one example of an inefficient process that increases costs across the healthcare system--for both providers and patients--and one which routinely jeopardizes patient care by often delaying or denying treatment.

PA was initially used by health insurers to minimize the overuse of expensive healthcare services such as MRIs, CAT Scans, and other cutting-edge diagnostics and medications. However, health insurers are now requiring physicians and other healthcare providers to secure prior authorization for routine tests, medications, and procedures that fall well within accepted standards of care. In fact, many health insurers are now requiring PAs for generic medications.

In addition to PA, my proposal addresses the issue of step therapy. Step therapy is routinely used by health insurers to limit how much is spent covering patients’ medications. Under a step therapy protocol, a patient must try one or more drugs chosen by their insurer—usually based on cost, not medical, considerations—before coverage is granted for the drug prescribed by the patient’s healthcare provider. Patients may be required to try one or more alternative prescription drugs that are of lower cost to the insurer, but which may not be the best therapy for them. While this process may seem benign, patient health often declines as they “try and fail” on alternative medications. I believe there needs to be a balance between cost control and patient need. This proposal would establish a basic framework for when it is medically appropriate to exempt a patient from step therapy.

The criteria for whether to approve a prior authorization request or to require step therapy varies widely from one health insurer to another, frustrating providers who want to treat their patients according to accepted clinical protocols and guidelines. In other words, they want to do what is in the best interest of their patients. While my proposal does not prohibit the use of PA or step therapy by health insurers, it does promote transparency and it establishes important safeguards to ensure that patients get the care they need.

I hope you will join me in supporting this legislation to help physicians and other healthcare providers deliver better and more appropriate care to their patients.

Introduced as HB225