OPINION:
When Maryville, Wash., resident Robin Sparks was diagnosed with Stage 3 non-Hodgkin lymphoma, she and her doctor quickly came up with a care plan. But midway through her chemotherapy, when her doctors needed a CT scan to determine whether the treatment was working, her health insurer said no. The routine test was denied multiple times. Their reason? It wasn’t necessary for Robin, despite her doctor ordering it.
Unfortunately, Robin’s story is not unique. Across the country, patients are facing dangerous delays due to an antiquated paperwork practice known as prior authorization, wherein insurance companies require patients to get advance approval before delivering treatments or medications.
Prior authorization was designed to be a tool to keep health care costs in check, but it has become a pervasive barrier to care. It’s a feeling that is familiar to many Americans: calling your doctor’s office multiple times, filling out the same form and then faxing it over to your insurance provider, then waiting days or even weeks to get a decision.
I’ve met with patients, their families, and their providers from across Washington state about the harms this practice can have for many types of illnesses and conditions. Delays are not only frustrating; they can also make conditions worse. Rick Timmins from Whidbey Island told me how his insurer delayed granting prior authorization to allow his dermatologist to assess a small, painful lump on his ear. During that months-long delay, the tumor tripled in size and was diagnosed as a malignant melanoma that had a high risk of spreading, requiring surgery and immunotherapy.
These stories are heartbreaking and infuriating.
Doctors report spending 13 hours each week on average trying to get prior authorization requests approved. In many cases, they’re forced to defend decisions already based on widely accepted standards of care. The American Medical Association says that 94% of prior authorization delays result in worse health outcomes.
Reforming this antiquated practice has significant bipartisan support in Congress. I recently reintroduced the Improving Seniors’ Timely Access to Care Act with a bipartisan coalition of members. This commonsense legislation modernizes and streamlines the prior authorization process for Medicare Advantage plans, which serve over 33 million seniors.
The bill would help get faster decisions on routine services, create a standardized electronic form across Medicare Advantage, and require information reporting from insurance companies about what they’re approving and denying.
Last year, the Biden administration took a critical step forward by announcing new regulations to limit unnecessary prior authorization requests that mirror many aspects of our legislation. While this was progress, we must still pass legislation to improve care for seniors and give providers certainty about the process going forward.
The health care community largely agrees. More than 500 national and state organizations, including patient advocacy groups, hospitals, and provider groups, back our bill. In 2022, the legislation passed the House with overwhelming bipartisan support, but it wasn’t taken up in the Senate. We know we only help people when we get legislation to the president’s desk. That’s why we must finish the job and get this bill all the way there.
Robin Sparks survived cancer. After months of uncertainty and repeated denials, she finally got the scan she needed and completed her treatment. But she knows others may not be as lucky. I’m fighting alongside Robin and thousands of others to make sure no one else has to delay or abandon care because of outdated red tape. If we want a health system that puts patients first, we must fix prior authorization now.
Congress can make a real difference in the lives of millions of seniors. Let’s deliver the care patients deserve when they need it most.
• U.S. Rep. Suzan DelBene represents Washington’s 1st Congressional District. She serves on the House Ways and Means Committee, which is at the forefront of creating a more equitable tax code, health care reform, trade deals, and lasting retirement security.
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