Pennsylvania Legislature Acting Immediately Could Make New Treatments More Easily Accessible for Chronic Illness Patients Spotlight PA

Spotlight PA Independent, nonpartisan newsroom operated by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media. Sign up for our free newsletter.

HARRISBURG — Chronic patients may find it easier to get insurers to approve new treatments under a bill that Pennsylvania lawmakers are scrambling to pass on the last day of Congress.

of 67 pages The bill applies primarily to private insurers, removing preapproval for emergency care, standardizing timelines for insurers to approve or deny requests for treatment, and discouraging patients from trying cheaper drugs first. We assure you that your doctor can request a plan to cover your medications.

Proponents say the bill would allow health care providers to spend more time on treatment rather than fighting with insurance companies, giving patients more clarity and flexibility when deciding on treatment options. I’m here.

But changes to a topic as complex as state insurance laws can quickly become troubling, even when the bill has bipartisan support. And sticking a needle among many wealthy lobbies has prevented similar changes from passing for more than a decade.

Industry associations of insurance companies, hospitals and doctors have all lobbied heavily in the Capitol. The Pennsylvania Insurance Federation, in particular, spends millions of dollars each year trying to influence legislators.

“It’s a big bill. The details matter,” said Federal CEO Sam Marshall. He did not specify what concerns he had about the bill, but said “all sides are cooperating in good faith.”

The bill has the support of more than 70 specific condition organizations, including organizations representing patients with diabetes, arthritis and multiple sclerosis, among other chronic diseases. They argue that the bill will provide patients with faster access to medical care.

At the center of the proposal is an effort to change two key components of America’s healthcare system: preapproval and tiered treatment.

Pre-approval allows an insurer to determine whether a medical procedure or treatment is medically necessary before deciding to cover it. Step therapy is provided by the insurance company. cost saving measuresasks the patient to try one drug to see if it doesn’t work before approving the patient’s preferred treatment.

The bill does not eliminate either practice entirely. Instead, insurers should offer both waivers, create a standardized process for doctors to apply for approval or request waivers, and for patients to challenge insurer decisions.

Create a standardized electronic form for requesting approval, set statutory timelines for responding to requests (72 hours for urgent requests and 14 days for non-urgent services), and obtain approval from insurance companies. Request written notice explaining the denial and provide insurance to the state. The department that reviews decisions.

The bill also allows physicians to challenge insurance company decisions directly with physicians employed by insurance companies.

Overall, this “creates a new and more effective process for pre-approval of health services, keeping everything consistent and transparent from start to finish,” said Christine Phillips, the bill’s sponsor. Senator Hill (Rep., York) said: .

Private insurers defend review powers as a cost control tool necessary to keep premium rates down. However, patient and provider advocates argue that these administrative actions favor insurers and reduce their ability to make important medical decisions.

“It’s like having a pipe burst in your house and being told you shouldn’t call the plumber and try to mop it first,” says Mark Lopatin, a retired rheumatologist in suburban Philadelphia, of Spot. told Wright PA. Lopatin serves on the board of the Pennsylvania Medical Association, which supports the bill.

He has seen patients who have been asked to stop taking medications they had been taking for years because they changed insurance companies and the medications would not be covered under the new plan until they tried cheaper alternatives. expressly grants an exemption from step therapy in such circumstances.

Lopatin’s experience is not unique. 2021 American Medical Congress Investigation Of 1,000 physicians nationwide, 93% reported encountering treatment delays due to pre-approval, and 82% said these delays led to patient abandonment.

“Scientific breakthrough [and] Advances in medicine often mean that diagnoses can be managed and treated,” says Emma Watson, chief lobbyist for the American Cancer Society’s state chapter and representative of other patient groups. said. “Patients need the ability to quickly assess their condition together with their health care professional to find the course of action that best fits their individual health needs.”

In some cases, the bill only brought state insurance laws last amended in 1998 into line with federal law. For example, the proposed ban on pre-approval for emergency care would: federal law But health care providers have since challenged That law in court.

Changes to the state’s insurance law have been under consideration for years, but have not reached the governor’s desk.

The current proposal passed the Republican-controlled state Senate unanimously in June, but “a lot of people were concerned when it passed through the House,” said House Insurance Committee Chairman Tina Pickett. Republicans, Susquehanna) said recently.

Her committee approved the amendment on September 20, retaining many important provisions. Watson of the Patients Coalition still supports the bill. Marshall of the Insurance Federation said he was still considering the change.

Pickett said he expects more conversations with stakeholders before the bill is put to a final vote.

Both Democratic Gov. Tom Wolfe and House Speaker Brian Cutler (R-Lancaster) have expressed interest in seeing through pre-approval changes as the two-year term comes to an end.

Wolf spokesperson Beth Rementer said in an email that ensuring patients receive timely medical services is “a key factor in ensuring patient access to quality care.” He said that concern was at the heart of discussions on the bill.

The bill is currently awaiting a floor vote in the state House, and the state Senate will have to approve the changes before the bill reaches Wolfe’s desk.

The House has three days left in session before the end of the year. The Senate has six bills that must approve the House’s edits.

while you are here… If you learned anything from this story, pay upfront and become a member Spotlight PA someone else in the future spotlightpa.org/donateThe spotlight PA is foundation and readers like you A person committed to accountable journalism that delivers results.