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    Inefficient payer approval processes fail patients, frustrate docs

     

    The AACU recently joined a national coalition led by the AMA to direct reform of utilization management programs, including prior authorization.

    These 21 principles are divided among five broad rules for proper care (see, “Five broad rules for proper care,” below).

    In addition to prior authorization processes, these standards were designed to apply to fail-first requirements, as well. Fail-first, euphemistically called “step therapy” by insurers, is “very disruptive to patient care,” according to Dr. Frankel.

    “Instead of letting the patient know if a drug is covered or not, the payer insists that alternative medications be tried before it is authorized,” Dr. Frankel added. “This is particularly problematic at the start of the year when many patients have problems obtaining the medications that they are currently using effectively.”

    The above-referenced legislation in Florida, as well as a bill in Maryland (MD SB 768), impose transparency requirements on step therapy. A similar provision in both proposals prohibits insurers from adding fail-first changes during a plan year. Maryland is also one of two states that crafted legislation based on a 2016 Georgia law, the Jimmy Carter Cancer Treatment Access Act, that specifically impacts prostate cancer patients (MD HB740/SB919).

    Have you read: What will replace the Affordable Care Act?

    The model bill says that an insurance company cannot insist that patients fail to respond to other treatments before trying a physician's desired course. The law would only apply to health plans that cover the treatment of advanced, metastatic cancer, which typically involves stage IV patients.

    The prior authorization process “exemplifies the kind of clerical work that now consumes about half of physicians' time in the office, while less than 30% of the day is spent on direct clinical care,” according to the AMA. “These growing diversions from patient care serve as physicians' biggest source of professional dissatisfaction.”

    “If we do not stick with it, the patient loses big time,” Dr. McWilliams said. The AACU, for one, develops innovative tools and promotes comprehensive reforms that empower urologists in their fight against such distractions from patient care.

    Next: Five broad rules for proper care

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