Minnesota legislators are weighing commendable reforms to health insurance’s prior authorization process. The targeted approach under consideration is sensible.

By Editorial Board

The Minnesota Star Tribune

March 30, 2024 at 11:00PM

Kim Munson and her daughter Kinsley. (Provided by Kim Munson)

Opinion editor’s note: Editorials represent the opinions of the Star Tribune Editorial Board, which operates independently from the newsroom.

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Kim Munson’s daughter Kinsley was only 4 years old when doctors delivered a serious diagnosis: the little girl had Type 1 diabetes, and celiac disease as well.

Now 12, Kinsley has come a long way from the days when she’d cry or hide to avoid the frequent injections diabetes treatment requires. The preteen takes an active role in managing the insulin pump and continuous glucose monitoring system that keep her diabetes in check.

While Kinsley moves toward independence, her mom would like to break free of the paperwork that the Lakeville family’s insurer requires every three months for infusion sets and every six months for glucose monitoring supplies. The process involves submitting information from her medical record to the insurer and the supplier, apparently to document ongoing need.

As Kim asked in an interview, Type 1 diabetes is incurable, so what’s the point of the red tape? There’s also no room for delays or error. “There’s so many moving parts. If at any time there is a misstep, we are in danger of not having the supplies that ultimately keep her alive,” she said.

The process frustrating the Munsons is known as “prior authorization.” It means that, in order for certain treatments or procedures to be covered, your health insurer reviews and approves the care recommended by your medical provider. This year, Minnesota legislators are putting a commendable spotlight on the process and sensibly considering reforms to alleviate paperwork burdens for some families and physicians.

The legislation, whose authors include three Democrats who are physicians as well as a Republican chiropractor, does not eliminate prior authorization. Instead, it takes a targeted approach, prohibiting prior authorization on services where a delay of care can be deadly. These include: substance use disorder medications, outpatient mental health treatment, pediatric hospice services and cancer treatments complying with best practice guidelines.

Ongoing conditions like Kinsley’s are also addressed. The bill, SF 3532/HF 3578, states that authorization for treatment of a chronic health condition would not expire unless the standard of treatment changes.

“All Minnesotans should be able to get behind legislation that removes prior authorization for cancer, mental health, substance use disorder, and chronic conditions,” the Minnesota Medical Association said. The MMA, which represents over 10,000 state doctors, is one of the bill’s most influential backers.

Insurers have testified against the bill, citing among objections that prior authorization is a critical tool to control care costs. That is a fair concern, though one that may not reflect added compliance costs for medical providers. Insurers also argue that prior authorization review enhances patient safety.

Still, the push for change at the Capitol is appropriate. While Minnesota enacted some prior authorization reforms in 2020, the state’s doctors are correct in saying there’s more work to do. It is entirely reasonable to continue finding ways to reduce the hoops patients must jump through. So is reducing the time physicians spend on prior authorization, particularly in the midst of a historic health workforce shortage.

“Physicians and their staff spend an average of almost two business days (14 hours) each week completing [prior authorizations],” according to a 2022 survey by the American Medical Association.

Recent legislative testimony from Children’s Minnesota underscored the need for further reforms. The pediatric medical system has 30 employees dedicated to handling prior authorization. In 2023, there were 81,000 requests for nearly 58,000 patients.

The Children’s staffer also relayed two alarming incidents: a prior authorization that rejected a liquid medication for a 2-month-old and suggested a tablet instead. Another: a young boy on medical assistance whose doctor’s cancer treatment was rejected, with the alternative including drugs not approved for use in his age group.

While the Children’s staffer said over 95% of prior authorization requests do get approved, she also cautioned that the process too often results in care delays and adds to families’ anguish.

This debate is a reminder that health reform is dauntingly complex. One well-meaning adjustment can potentially yield unhelpful, unintended consequences, such as hobbling one of the system’s few cost-control mechanisms. That’s why the targeted approach under consideration is sensible, though it may need further refining.

It’s also critical to note that the state reforms would only apply to those with insurance plans regulated by the state. That does not include most people — such as the Munsons — who get their coverage through a large employer because these plans are federally regulated.

But as Kim noted, changes may spur reforms to plans like hers. “I believe there are cascading effects to these laws,” she said. The proposed Minnesota reforms would send “a clear message to insurance companies. Patient lives are valuable. Their time and peace of mind is valuable. And their ability to receive needed supplies and medications without undue, continued hardship to satisfy a paper trail for an insurance company ... is the least that can be done to ensure our health and safety.”