Patient Struggles Highlight Need for Urgent Prior Authorization System Reform

By Consumers for Quality Care, on March 6, 2024

Christopher Marks, a patient battling for coverage of a higher dose of a diabetic medication, has encapsulated a wider issue—prior authorization hurdles within our health care system, according to KFF Health News.

Although prior authorization is meant to be a cost-control measure, patient advocates suspect that some insurers are exploiting it to deny patients care.

In Marks’ case, he had to file several appeals with his insurer to access and stay on Mounjaro, a medication that was keeping his blood sugar in check but costs more than $1,000 per month. After using up his initial dose, he was again denied coverage by his insurer. “That is beyond frustrating. People shouldn’t have to be like, ‘It’s not worth the fight to get my medical treatment,’” Marks said.

While the Centers for Medicare & Medicaid Services (CMS) recently finalized a new rule that will soon reduce long and laborious decision times typically associated with the prior authorization process, states are looking to enact additional protections. Last year alone, more than half of state legislatures proposed nearly 100 bills aimed at reforming prior authorization requirements. These bills offer a wide range of solutions, including requirements to ensure faster response times, public reporting of insurers’ decisions, and innovative programs like “gold carding” to streamline the volume of requests. Gold carding exempts physicians from the prior authorization process if an exceptionally high amount (typically 90 percent) of their requests are approved by insurance companies.

State lawmakers see their work as a necessary measure to address some of the issues associated with the prior authorization process. In 2018, health insurers signaled a willingness to improve the prior authorization process, but since then have shown little progress in achieving these goals. And while the CMS rule is set to take effect in 2026, it doesn’t look at gold carding, and does not apply to prescription drugs, which accounts for 39 percent of all prior authorization requests.

CQC applauds actions to reform the prior authorization process and urges both lawmakers and providers to eliminate needless, burdensome processes that prevent consumers from receiving the medical care they need.