Insurers, Physicians at Odds Over Paper Trail

For Juan Thomas of the California Medical Association, it’s a no-brainer.

“Right now, the way preauthorization forms are, there are so many types of preauthorization forms, with different ones from different health plans and health insurers. They all want different types of information,” Thomas said. “And if the physician doesn’t have the correct form for the correct insurer, they have to hunt it down. Physicians spend a lot of time on this issue, and that’s time away from patients.”

Senate member Ed Hernandez (D-Los Angeles) addressed the issue in SB 866, which successfully made its way through the Senate and is up for a vote before the Assembly Committee on Health today. It would require insurers to adopt a standard form, and it would give them a deadline of two business days to respond to medication authorization requests.

“One of the tenets of health care reform is standardization,” Thomas said, “and this seems to us to be one of the areas where you could have a significant impact on cost, without sacrificing quality.”

Under that plan, the burden of paperwork does not go away, it just shifts to health plans and health insurers, according to Patrick Johnston, president and CEO of the California Association of Health Plans.

“We have a stance of opposed unless amended, and we continue to work with the author,” Johnston said. “The standardized form we recommend would be a template rather than a single, required, all-inclusive document.”

With one form for all insurers and all medications, Johnston said, SB 866 has the potential to actually be more confusing, if all medications were listed on the same questionnaire. But the issue with bigger implications for the industry and for patients might be the 48-hour response requirement.

“The complexity of a patient’s medical condition, the side effects of the drug and the cost of the drug, those all contribute to taking some time to review and make a decision,” Johnston said. “Treating every prior authorization as an urgent matter doesn’t make sense. Health plans don’t want to fall out of compliance, so realistic time frames are better than treating everything with the same level of urgency.”

In many cases now, he said, deadlines for response to prior authorizations have been about 5 days, and the national standard is about 15 days.

But for Gabriel Halperin, medical director of the California Wound Healing Medical Group in Southern California, time is short when people are in pain, even if it’s not a life-threatening emergency.

“The trouble I see, for instance, with peripheral neuropathy patients,” Halperin said, “is that these patients have a choice — to live with the pain, to take narcotics or to take appropriate medications.”

Those appropriate medications have to be pre-approved, Halperin said. And sometimes those approvals take a long time, especially when cheaper medications have to first be proven ineffective.

The way Johnston sees it, “The physicians in support of this have a case to make to reduce the paperwork requirements,” he said. “However, rushing to judgment on expensive, patented medication is not as compelling a concern.”

In other news, the debate over the contractual status of physical therapists was put on temporary hold yesterday. At issue is whether AB 783 is a clean-up-outdated-language bill that will aid physical therapists, or a power play by physician groups that could hurt those therapists’ livelihood.

It was slated for a vote yesterday in the Assembly Business and Professions committee, but bill author Assembly member Mary Hayashi (D-Castro Valley) withdrew it for now.

“We’re putting this bill over,” Hayashi said at the committee hearing. “We are meeting with the opposition and trying to work on a compromise this week.”

Also yesterday, advisory bill AJR 13 was passed in the state Assembly. Authored by Assembly member Ricardo Lara (D-Bell Gardens), it asks the federal government to do its part to beef up the medical professional work force in California.

“There is a lack of medical residencies, and many medical graduates find themselves deep in debt after finishing their training,” Lara said. “This urges the president and Congress to increase the number of medical professional graduates, to keep pace with the growing need in California.”

The resolution passed 55-6.