Her insurer stopped approving her drug that worked. Will a new state law help?

Sandra Johnson was responding well to an injectable drug to treat her persistent asthma, but then her insurance company stopped allowing her to get it in a process called “prior authorization.”

Kimberly Paynter/WHY

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Kimberly Paynter/WHY

Sandra Johnson was responding well to an injectable drug to treat her persistent asthma, but then her insurance company stopped allowing her to get it in a process called “prior authorization.”

Kimberly Paynter/WHY

Sandra Johnson started feeling short of breath a few years ago, and at times it drastically limited what she could do.

“When I get up to walk from my bedroom to the bathroom, I’ll be so out of breath that I’ll have to sit down … to get ready to get up to take a shower,” says Johnson, who lives in Plainfield, New York. jersey

He has severe persistent asthma, treated with an injectable medicine. Your doctor had to get approval from your insurance company to prescribe the drug, initially. And then, a few months ago, his insurer required prior authorization again, for the same treatment. This time, the answer was no. Johnson has been without the drug for months.

Many patients have had this experience. Doctors have long complained about how the prior authorization process makes it difficult to care for patients. Insurance companies say the point is to make sure doctors prescribe the most cost-effective treatments.

States are responding to complaints from doctors and patients and are pursuing legislation to try to establish some ground rules on prior authorization. New Jersey was the second state to pass such legislation after Washington State. D.C. adopted a similar law late last year, and more than two dozen states have similar bills moving through the legislative process.

The drug Johnson had taken made a huge difference in his quality of life. She says she felt better and could return to her job as a clinical coordinator, run errands and go shopping without problems.

“I don’t understand why I’m being denied when this medicine I’ve been taking has worked for me,” she says.

The problem also affects doctors, says Tina Shah, a pulmonary and critical care physician in West Orange, New Jersey, and also the chief clinical officer of Abridge, a medical AI company.

“This causes so much moral distress that I often go home and have to decompress because I know I can be the best doctor, but because of prior authorizations I often can’t provide the best care,” he says.

More than 90% of doctors say their patients have had to delay their health care because of prior authorization, according to a 2022 survey by the American Medical Association. One-third of doctors in this survey say the delay led to serious problems for their patients, such as a life-threatening event or hospitalization.

Shah recalled one of her patients, who had a history of endometrial cancer and had been trying to figure out the cancer’s status for months. The insurance company denied prior authorization for the medical imaging. This patient ended up in intensive care with a life-threatening blood clot and underwent medical imaging, which also showed that the cancer had spread.

“He finally got the answer he desperately wanted for the past few months,” says Shah. “But now he’s battling much more advanced cancer and needs to be on blood thinners for life.”

The new law passed in New Jersey this January aims to speed up the process. Once it takes effect next year, health insurance companies must decide on prior authorization within three days. If a doctor says their patient needs medication urgently, the insurance company must approve or deny it within 24 hours.

Catherine Trillo has been a registered nurse in New Jersey for more than 30 years and says she sometimes spends hours each day dealing with this problem on behalf of patients. He says the reform project will mean a big change for patients and medical staff.

“If this is the last thing I do in my career, it’s amazing … it makes a permanent step toward improving health care.”

Shah echoes that sentiment.

“I’m actually hoping that I’m not just a widget in the health industry,” he says.

“When this bill goes into effect in January 2025, we will hear it,” he says. “It will allow me to do what I was really trained to do to spend time with my patients and try to make them feel better.”

Ward Sanders represents health insurance companies in this debate, as president of the New Jersey Association of Health Plans.

He said it’s good that the law requires faster decisions, but added that prior authorization isn’t just red tape, the process is in place for a reason.

“The purpose of prior authorization is to provide the right care at the right time and in the right setting and to allow efficient allocation of resources.”

He said, for example, insurance companies will sometimes ask doctors to consider cheaper drugs that achieve the same therapeutic effect. He pointed to a line in New Jersey’s state budget documents last year that said prior authorization saved the state’s health insurance program for public employees nearly $100 million.

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