Health Insurance Made Me Jump Through Hoops To Get The Treatment I Need. It Cost Me My Job.

My husband just got a new job. Congratulations, right? Not if you suffer from a chronic illness. A new job meant new health insurance, and I had psoriatic arthritis, a potentially debilitating autoimmune disease. What should have been an exciting time of new beginnings for our family turned out to be filled with anxiety. The medications I have been taking for the past 14 years to treat my illnesses require prior authorization and our new insurance company is denying them prescriptions. My rheumatologist started the appeals process. Meanwhile, my medication ran out and I was worried.

What happened to me was not an anomaly. Patients across the country are waiting and wondering as they struggle to gain access to treatment plans prescribed by their doctors. Deputy Dr. promoted to the new bill. Kim Moser of Northern Kentucky wants to reform the commonwealth's pre-clearance process with House Bill 317.

If you've ever had a medical procedure, you've probably come across consent before. HealthCare.gov defines it as your health insurance decision determining whether a particular treatment plan, prescription drug, or permanent medical device is “medically necessary.” Determine what portion (if any) your insurance will pay. Prior authorization is time-consuming for healthcare providers and creates stress for patients waiting for care.

Prior consent delays treatment and harms patients

A 2022 American Medical Association survey found that 94 percent of treatments were required when prior authorization was pending. These delays result in 25% of hospitalizations.

Prior authorization issues: The process needs to be overhauled to improve the health of Kentuckians

I have been taking the same biologic for my autoimmune psoriatic arthritis since 2010. I know this struggle well. The first time I was denied a prescription was soon after my diagnosis. My insurance company preferred other, less expensive treatments and asked me to try them first. This process is called "step therapy". I call it a nightmare.

According to an American College of Rheumatology patient survey, nearly half of patients (46%) said their insurance stipulates the need for staged therapy, and another 48% of patients reported that providers must obtain prior authorization before obtaining a prescription.

Patients are paying the price for America's medical bureaucracy

Prior authorization, steps and levels of therapy should ensure a high level of patient care and avoid waste, fraud and abuse. But when I jumped through the necessary hoops and took the medication my insurance company required instead of the medication my rheumatologist recommended, my condition only got worse. In six months I went from walking with a cane to walking in bed. I quit a job I loved and plans to have another child were cancelled. My heart is broken and this could have been prevented.

“Prior authorization has been a bureaucratic hurdle for health services,” the representative said. Moser wrote in an email to The Courier Journal. “This causes dangerous delays for patients, frustrating and costly administrative burdens for healthcare providers and insurance companies.”

That's certainly true for me. After months of application and what I can only imagine was a mountain of paperwork from my care team, I was finally cleared to start biologic treatment. That was a game changer for me. This restored my quality of life and in 2015 I had a beautiful son.

I feel like I have won. But then my husband got a new job and I had to struggle again. This time it was an opportunity to get medication that worked for me and I knew what my life would be like without it. That's hard for me, and I see nothing but greed in this process. The insurance denial letter said they denied my treatment because "there are less expensive but equally effective treatments for many conditions based on clinical guidelines." This tells me that money is the driver, not my responsibility to take care of it. If the drug doesn't work and I lose my job in the trial process, what if another drug helps save my co-pay?

I understand that these guidelines are there for a reason, but what I struggle with is why insurance companies require prior authorization for chronic disease treatment. I don't see how they can justify rejecting the current treatment plan.

Kentucky needs prior consent reform

The American Medical Association, along with 16 other physician, patient, and health organizations, including the American College of Radiology, the American College of Rheumatology, and the American Academy of Family Physicians, supports prior consent reform. One way to win is the gold card system. In 2023, 30 states introduced prior authorization reform legislation. Kentucky is one of them. So far, Texas, West Virginia, Louisiana and Michigan have passed laws supporting gold carding.

Deputy Dr in the last two legislatures. Moser had previously sponsored a bill to reform the Commonwealth, but the bill was not even read. This year's HB 317 was supported by 10 Kentucky medical societies.

Many have called for pre-authorization reform at both the state and federal levels. With Texas leading the way, the Gold Card Act of 2023 has the potential to bring prior authorization reform to healthcare providers and their patients nationwide. Additionally, on January 17, the Centers for Medicare and Medicaid Services finalized new regulations regarding prior authorization for certain Medicare and Medicaid providers. Starting in 2026, payers must submit prior authorization decisions within 72 hours for urgent applications and within seven calendar days for other applications. This will significantly reduce the patient's waiting time to receive the necessary treatment. The payer must also provide a reason for not accepting the application, as well as follow up and publicly notify the prior authorization action.

KY requires universal lead screening. Our home is poisoning our son and we don't know how.

What is the "Gold Card" procedure for pre-approval?

The “gold card” does not eliminate prior approval, but helps simplify the process for experienced physicians with high prior approval approval rates. This is a waiver system in which physicians are issued or hold a “gold card” to submit prior authorization requests for certain drugs and services. Kentucky's HB 317 does not introduce gold cards like other state laws, but it does allow health care providers to be exempt from prior authorization requirements if 90% of applications are approved. .

Our healthcare system needs to be overhauled and a prior authorization process is a good start. I want my rheumatologist to focus on my care and I want uninterrupted access to the maintenance medications I need to maintain my quality of life. I don't have to endure unnecessary relapses of my disease while I wait for pre-authorization just to line the insurance company's pockets.

Bonnie Jean Feldkamp is the opinion editor for The Louisville Courier Journal. You can contact her via email at BFeldkamp@Gannett.com or on social media @WriterBonnie.

This article first appeared in the Louisville Courier Journal: Prior consent harms patients and denies care. KY requires a Golden Ticket

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