PLAINFIELD, New Jersey — Sandra Johnson, a resident of Plainfield, New Jersey, has been grappling with severe persistent asthma for years. The condition significantly limits her daily activities, often leaving her short of breath and unable to perform simple tasks such as walking from her bedroom to the bathroom without taking breaks. To manage her asthma, Johnson relies on an injectable drug. However, her insurance company recently denied her request for prior authorization to continue receiving the medication, leaving her without treatment for months.
Johnson’s experience is just one example of the challenges patients face when it comes to prior authorization. Doctors have long complained about how this process interferes with providing timely and effective care. Insurance companies argue that prior authorization helps ensure cost-effective treatments are prescribed. In response to widespread concerns, several states, including New Jersey, have introduced legislation to address this issue. New Jersey became the second state, after Washington, to pass such a law. Similar bills are also making their way through the legislative process in over two dozen states.
The denial of medication has had a significant impact on Johnson’s quality of life. She previously felt better and was able to resume her job and perform everyday tasks without difficulty thanks to the medication. Doctors, like Tina Shah, a pulmonary and critical care specialist in West Orange, New Jersey, and the chief clinical officer of Abridge, a medical AI company, also feel the effects of prior authorization. They often find themselves unable to deliver optimal care due to the bureaucratic hurdles imposed by insurance companies.
According to a survey conducted by the American Medical Association, over 90% of doctors have had patients delay necessary medical care due to prior authorization requirements. This delay has resulted in serious consequences for some patients, including life-threatening events and hospitalizations. Doctors, like Shah, have witnessed firsthand the harmful impact of these delays on patients’ health. She highlighted the case of a patient who ended up in intensive care due to a blood clot after the insurance company denied prior authorization for medical imaging. The imaging, when finally obtained, revealed that the patient’s cancer had spread.
To address these issues, New Jersey passed a law in January that aims to expedite the prior authorization process. Under the new law, health insurance companies are required to make decisions regarding prior authorization within three days. If a doctor deems a medication urgently necessary, the insurance company must approve or deny the request within 24 hours.
Catherine Trillo, a registered nurse in New Jersey, believes that this reform will bring significant improvements for patients and medical staff. Spending hours each day navigating prior authorization issues on behalf of patients, she sees the reform as a step towards enhancing healthcare delivery. Shah also expressed optimism about the upcoming changes and hopes that they will allow healthcare professionals to focus on providing quality care to their patients.
While the new law has been welcomed by healthcare professionals and patients, Ward Sanders, the president of the New Jersey Association of Health Plans, warns against dismissing the importance of prior authorization. He contends that the process serves the purpose of ensuring the right care is provided in the right setting, while also promoting efficient allocation of resources. Sanders argues that insurance companies often ask doctors to consider more cost-effective alternatives that deliver the same therapeutic effect.
As the debate around prior authorization continues, it is clear that finding a balance between efficient resource allocation and timely access to necessary treatments is crucial. The new legislation in New Jersey represents a step towards addressing some of the concerns and challenges associated with prior authorization, signaling potential improvements in patient care and healthcare delivery in the future.