Lawmakers Take on Prior Authorization Reform as Health Insurance Frustrations Mount, Managed Care
The Guardian, Dec. 31, 2024. Nearly one in four doctors say the practice of prior authorization has led to serious issues for patients.
--------
In the wake of the killing of Brian Thompson, the CEO of UnitedHealthcare, and the outpouring of frustration about insurance coverage, prior authorizations have emerged as a particular roadblock in healthcare. Prior authorization requires medical providers to get an insurer’s approval before patients receive healthcare or medications.
“As a physician, prior authorization is the number one frustrating thing of practicing outpatient medicine right now, far and away,” said Dr Gabriel Bosslet, a pulmonologist and professor at Indiana University School of Medicine. “I spend more time trying to figure out how I need to get this medication approved than I do seeing the patient and making a diagnosis and writing the prescription.”
Originally intended to control the costs of certain medications and treatments, the frequency of prior authorization requirements has risen in recent years and they now plague common and inexpensive care. “This didn’t really happen five or seven years ago,” Bosslet said. Miranda Yaver, assistant professor of health policy and management at the University of Pittsburgh, noted that “prior authorization is something that really proliferated with the growth of managed care in the United States”.
One study found reforms such as setting maximum time periods for insurers to respond and standardizing requests would help give patients needed care. Several states and Washington DC have passed laws to reform prior authorization practices. A federal bill that would expedite authorizations like these for Medicare Advantage plans was also reintroduced this year in Congress. In January, the Centers for Medicare and Medicaid Services finalized a new rule to streamline prior authorizations as a way to cut costs.
Nearly one-quarter (24%) of doctors say that prior authorization has “led to a serious adverse event for a patient in their care”, according to a survey from the American Medical Association (AMA)...
https://www.theguardian.com/us-news/2024/dec/31/health-insurance-prior-authorization
--------
Wiki - Managed Care. The term managed care or managed healthcare is used in the U.S. to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ('managed care techniques').
It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
.. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs.
Managed care is now nearly ubiquitous in the U.S., but has attracted controversy because it has had mixed results in its overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on U.S. health care delivery, which underperforms in terms of quality and is among the worst with regard to access, efficiency, and equity in the developed world.
.. Dr. Paul Starr suggests in his analysis of the American healthcare ('The Social Transformation of American Medicine) that Richard Nixon, advised by the "father of Health Maintenance Organizations", Dr. Paul M. Ellwood Jr., was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care...
https://en.wikipedia.org/wiki/Managed_care