Unable to make peace on their own with Minnesota's health insurers, the state's doctors are pressing legislation that would make it easier for them to overcome "prior authorization" insurance hurdles when prescribing drugs to patients.
While acknowledging that insurance restrictions play a role in preventing waste and drug misuse, leaders of the Minnesota Medical Association said Thursday that many patients are denied their medications or preferred brands with no discernible reasons.
And state Sen. Melisa Franzen, DFL-Edina, said doctors waste thousands of hours and millions of dollars each year haggling with insurers over prescriptions held up by prior authorization. "While intended as a way to ensure high-quality, cost-effective medicine, it is often getting in the way," she said.
The bipartisan bill, introduced by Franzen and Rep. Tony Albright, R-Prior Lake, has long been expected. The medical association made prior authorization its top legislative target this year.
The proposal resurrects the inherent and long-running tension that erupts whenever an insurer steps in and says no to something a doctor orders.
Similar high-level arguments emerged 10 years ago over doctors' use of high-cost imaging procedures such as CT scans. In that instance, Minnesota physicians reached a cooperative agreement with some insurers to review and prevent overuse without strict prior authorization.
This time, direct talks with insurers did not produce an agreement on improving prior authorization and making it a more accurate filter to snag inappropriate prescriptions, said Dr. George Schoephoerster, leader of the medical association's task force on the issue. Most prior authorization reviews end with the prescriptions being approved anyway.
Insurers are working to improve the process, but relaxing or eliminating it would remove an important check that prevents wasteful and costly prescriptions, said Jim Schowalter, president and CEO for the Minnesota Council of Health Plans.
"There are things we need to do to push costs further down, not let them go up," Schowalter said.
The dispute might diminish next year, when a state-mandated electronic system for prior authorization is supposed to begin operation that will cut down on paperwork.
What doctors want now is a clearer set of rules, and a system that blocks prescriptions only if they contradict an insurer's formularies. The task force examined more than 1,000 medications that would likely be subject to prior authorization, and found only six instances in which Minnesota insurers all had the same rules.
In an era of standardized and evidence-based medicine, such variability means "it probably isn't a clinic safety issue," said Schoephoerster, a St. Cloud geriatrician. "It probably is money."
Franzen said savings from the denial of unnecessary prescriptions are canceled by the administrative costs for doctors and their clinics. A 2009 study in the journal Health Affairs estimated that clinics spent $68,274 annually per physician interacting with insurers.
Schowalter countered that only 145 of the 53,000 daily prescriptions received by Minnesota insurers for their fully insured and public health plans end up reviewed under prior authorization. The plans also would prefer simpler restrictions, he added, but can't make them uniform given that they are competing for business and often tailoring benefits for large, self-insured workplace health plans.