Insurance prior authorizations delay critical health care. Ohio bill to combat it could be improved

A doctor looks at an x-ray indicating lung cancer. (Getty Images.)

As a cancer physician, last year I was reminded that lymphoma does not wait for insurance company approval.

A patient in our clinic was diagnosed with diffuse large B-cell lymphoma, an aggressive cancer. The lymphoma was growing quickly, and one mass had caused her kidneys to fail. This was a high-stakes situation, because diffuse large B-cell lymphoma is curable in many cases with a combination of immunotherapy and conventional chemotherapy.

We knew the diagnosis and the treatment that was most likely to cure her, but we had a problem. After submitting our treatment plan to her insurance company, we learned that, like many cancer treatments it would be subject to a prior authorization (PA) process, which would delay starting treatment for at least a week.

With rapidly worsening kidney function while waiting for a decision from her insurance company, I had to urgently admit her to the hospital for intravenous fluids and to start therapy. This added an expensive and emotionally distressing hospitalization to her cancer diagnosis, but thankfully, after five days in the hospital, she recovered well. Some patients are not so lucky, with PAs delaying or denying necessary medical care with long-term harm.

Thankfully, physicians and policymakers have started to pay attention to this issue. Proposals such as Ohio House Bill 130 , sponsored by state Rep. Kevin Miller and a bipartisan group of cosponsors, seek to improve timely access to medical care.

Prior authorizations (PAs) are an insurance practice in which a health care practitioner must get approval from a patient’s insurance company for a medication, procedure, or service before the insurance company agrees to cover it. PAs have been shown to cost doctors and nurses significant time and can delay or deny evidence-based treatments. A 2023 study in the Journal of the American Medical Association showed 22% of cancer patients did not receive the recommended care from their physicians because of PAs. Additionally, in a survey of cancer physicians , 93% stated that PAs can delay life-saving cancer treatment and 31% stated the average delay for patient care was longer than five days.

As insurance companies increasingly use PAs to block or delay care, physicians, nurses, and patients have raised concerns about the practice. The Ohio State Medical Association has taken a leading role in advocating for physicians and patients on PA reform.

House Bill 130 is an initial effort to address these concerns. The bill proposes a ‘Prior Authorization Gold Card’ to streamline PAs. Physicians with a high approval rate for a specific medication or service would receive gold-card status, eliminating the need for future PAs for that item. If well structured, this policy could expedite some patients’ wait for care.

However, we want to highlight areas where HB 130 could be improved to enhance its impact on patient care.

The 2023 draft bill as well as an updated version set a high bar for gold card qualification. The latest version requires 20 authorization requests for a given service or device over a 12-month period of time. Moreover, in the updated version of the bill, it is unclear whether and how drugs such as commonly used chemotherapy would qualify for gold card status.

The quantity of claims required is a major limitation in this bill’s potential to improve patient care. Few medications, services, or procedures are ordered by a single physician 20 times in a 12-month period.

The inclusion of provider groups in the updated version is a welcome change, though for small clinics and hospitals this barrier remains insurmountable for most services. This distinction matters.

In 2021, the Texas Medical Association successfully lobbied to decrease the minimum amount of claims needed from 20 to 5 in a given six-month period. Even with this adjustment to Texas’ law, only 3% of physicians and other health care practitioners received gold cards for any service in the first 2 years after passage.

We call on physicians, nurses, patients, and legislators to support three key revisions to House Bill 130:

1. Reduce the minimum number of requests to qualify for Prior Authorization Gold Cards.
2. Clarify the criteria for Gold Cards for commonly used drugs, such as chemotherapy.
3. Plan other mechanisms to bypass prior authorizations for physicians, such as automatic approval for chemotherapy regimens recommended by the National Comprehensive Cancer Network Clinical Practice Guidelines .

The authors of House Bill 130 should be commended for shedding light on an often-ignored topic. We hope with additional revisions and continued momentum, a final bill can ease administrative burden and improve care across Ohio.

Michael LaMonica is a medical student at The University of Cincinnati. Bryan Hambley, MD/MPH, is a blood cancer and bone marrow transplant physician at the University of Cincinnati College of Medicine. The views expressed are those of Mr. LaMonica and Dr. Hambley and not their institution or employer.

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