Opinion: Md. patients face burdensome insurance barriers to lifesaving health care. Lawmakers must act now to improve access

By Gene Ransom III

The writer is CEO of MedChi, the Maryland State Medical Society. His Twitter is @GeneRansom.

The COVID-19 pandemic delayed routine screenings and primary care visits, leading to worse health outcomes for many Marylanders and their families. Unfortunately, as we continue to emerge from the pandemic, health insurers are making matters worse and interfering with the relationship between patients and physicians by blocking access to critical and timely care. To alleviate these barriers, Maryland lawmakers must take action to help improve access to health care for patients, particularly those living with chronic conditions.

I’ve seen firsthand how Maryland patients, as well as patients across the country, have struggled to access lifesaving health care. In the name of cost containment, many Maryland insurance providers are increasingly adopting protocols, such as step therapy and prior authorization, that restrict patient access, create unnecessary hurdles for physicians, and ultimately improve insurers’ bottom lines at the expense of patients.

Step therapy requires patients to first try and fail a cheaper treatment not recommended by their physician before covering the original prescription or ordering a specific test. Prior authorization requires patients to obtain approval from a health insurer to determine if their treatment plan is medically necessary before the insurer will cover certain prescriptions, procedures, or tests. Insurers use these tactics to reduce health care spending, but in turn are blocking medication access for those who need critical care and driving up costs for patients.

The result is that these predatory tactics put insurance bureaucrats in between patients and their physicians. Nine out of ten physicians have reported delays in patient care waiting for insurers to authorize medications and 82% of physicians have seen that patients have abandoned necessary treatments due to authorization struggles with insurers.

Maryland patients living with chronic conditions such as arthritis, multiple sclerosis, and HIV require consistent and reliable access to the treatments and care they need to manage symptoms and control their illness. However, when faced with barriers like step therapy and prior authorization, patients may be forced to skip or abandon treatments, leading to even higher medical costs down the road, in the form of hospitalizations, emergency room visits, or long-term health issues.

Physicians in Maryland feel the harmful impacts of these barriers as well. Prior authorization and step therapy create an administrative burden for physicians, with many offices spending an average of two business days a week on prior authorization paperwork and processes. In addition, nearly 26% of physicians have reported waiting at least three business days for a prior authorization, time and resources that should be spent helping patients get the care they need. These tactics get in the way of physicians being able to prescribe patients the care they need at the moment they need it.

Fortunately, Maryland lawmakers are considering a pair of bills — House Bill 305 and Senate Bill 515 — which both increase transparency in these insurer tactics and reform a system that continues to allow health insurers to interfere with Maryland patients’ ability to access lifesaving health care. HB305 would allow a patient to stay on a prescription without another prior authorization if the insurer has previously approved the drug and the patient continues to successfully be treated by the drug, while also creating additional guidelines around the use and execution of prior authorization. SB515 expands guidelines for a provider to request an exemption for step therapy, including if the medication required first by an insurer will cause an adverse reaction, is expected to be ineffective, or the patient is already stable on a prescription selected by their physician. Both bills are crucial to ensuring patients can access timely and necessary health care.

We cannot continue letting burdensome insurance barriers impede on the relationship between physicians and patients. It’s up to Maryland lawmakers to help ensure patients across the state are able to get the care they need when they need it. Otherwise, patients will continue facing delays in lifesaving health care as a result of onerous insurance protocols.

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