with Paige Winfield Cunningham

Doctors and health insurers are butting heads in the Lone Star State over a new kind of effort to roll back red tape for American patients.

Starting Sept. 1, many Texas doctors will no longer have to obtain advance permission known as “prior authorization” from a health insurer before administering a procedure or prescription.

The new law will grant automatic approval for medical orders from doctors who have a strong track record of getting the greenlight from insurance companies. Providers have long complained about the hassle of submitting paperwork to insurance companies to get approval before a procedure or prescription. The process can leave patients waiting for days to learn whether their insurance will cover their medical care.

Texas doctors are celebrating the new law.

It will allow doctors to skip prior authorization for certain treatments if 90 percent of their medical orders for those services in the past six months were deemed medically necessary by health insurers. 

Ezequiel Silva III, a radiologist in San Antonio and a member of the Texas Medical Association Council on Legislation, has been frustrated with the status quo for a while. He says that doctors, for example, have had to admit patients to the emergency room with potential appendicitis because they cannot get an imaging study approved in a timely enough fashion.

“The frustration is partly the delays, partly the time required to explain the procedure to the [health] plan,” said Silva. “What I find frustrating is when I’m trying to get the studies approved, I’m talking to physicians outside of my specialty.”

Silva said that he was looking forward to the new law simplifying his practice and making it easier for patients to get care.

It's like TSA PreCheck.

Physician groups compare the new “gold carding” process to TSA PreCheck, where vetted passengers are allowed to bypass security in airports, and claim it will reduce red tape and delays. They insist the requirements of prior authorization have become increasingly burdensome.

A survey by the American Medical Association found that 94 percent of doctors report that their patients have experienced delays in care due to prior authorization. Some 30 percent of doctors say that the prior authorization process has led to a serious adverse event of a patient in their care.

“When prior authorization started to take hold a couple decades ago, it was intended for and focused on a particular number of very expensive new drugs and new diagnostic tests,” said Jack Resneck, a dermatologist and the president-elect of the American Medical Association. “The experience of physicians and patients every day is that it has expanded so much.”

But insurance groups warn the loss of prior authorization will open the door to medical fraud, error and overspending.

Insurance companies say that they use prior authorization for only a small percentage of medical services and products, which are considered experimental or at risk of overuse. 

David Allen, a spokesman for America’s Health Insurance Plans, a leading industry group for insurance providers, estimates that typically less than 15 percent of medical care is subject to prior authorization. Citing studies that show many Americans receive inappropriate or unnecessary care, Allen says that the prior authorization can “help ensure safer opioid prescribing, help prevent dangerous drug interactions, and help protect patients from unnecessary exposure to potentially harmful radiation for inappropriate diagnostic imaging."

Jamie Dudensing, who leads the Texas Association of Health Plans, told The Health 202 that the law lacked adequate checks to protect against fraud or unnecessary and even harmful medical intervention. She said that health plans weren’t opposed to having gold-card programs but called the 90 percent threshold “really low.”

“It’s not about having a gold-card program. It’s about using a gold-card program to basically just have a blank check and free pass and no accountability,” Dudensing said.

Dudensing also says the new law could endanger patients. Because health insurers often have more of a bird’s-eye view of all of the care a patient is receiving, they can flag whether a patient is prescribed multiple opioids by different doctors or drugs that could have a dangerous interaction.

Prior authorization reform is also receiving attention at the federal level.

Bipartisan legislation in Congress seeks to make prior authorization in Medicare Advantage plans less burdensome by establishing an electronic approval process and a real-time decision process for items that are routinely approved. 

The bill, whose chief sponsors include Suzan DelBene (D-Wash.), Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would also require Medicare Advantage plans to report to the Center for Medicaid and Medicare Services on their use of prior authorization.

But it's still unclear how changing prior authorization might affect health-care costs.

William Bleser, a researcher at Duke-Margolis Center for Health Policy who studies payment model reform, says it’s not that anyone, including insurers, really likes the current prior authorization process, but it’s one of the few checks on costly health care in a system where there are few ways to ensure that medical care is cost effective.

“The fee-for-service payment and delivery model is one of the reasons prior authorization seems to be the solution for handling these new, costly or low-evidence therapies that can be expensive. In that system there’s not a good way to have quality or cost accountability behind these decisions,” said Bleser, whose research looks at prior authorization reform outside of fee-for-service health-care models.

Still, Bleser says research is limited on the effect of prior authorization on health-care spending. There is some evidence that prior authorization may encourage the use of generic drugs as opposed to more expensive alternatives in Medicare and Medicaid, he told The Health 202. Other studies looking at individual drugs, however, often find that prior authorization has a neutral effect on spending.

“It may sort of zero itself out when you look at the cost of running the programs,” Bleser said.

Ahh, oof and ouch

AHH: Fauci warned that “America is going in the wrong direction” as coronavirus cases climb.

Anthony Fauci, chief medical adviser on the coronavirus to President Biden, confirmed that the federal government is considering revising mask guidance amid the spread of the more infectious delta variant, telling CNN’s Jake Tapper yesterday that the issue is under “active consideration.”

The director of the National Institute of Allergy and Infectious Diseases also said the government is looking at whether the coronavirus booster shot should be given to people who are immune compromised, such as transplant patients, people undergoing cancer chemotherapy and those with autoimmune diseases.

But Fauci reiterated that the resurgence in coronavirus cases is among the unvaccinated. “[I]t is really a pandemic among the unvaccinated,” he said. Thirty states have not fully vaccinated half of their residents, according to CDC data. 

OOF: Rep. Clay Higgins (R-La.) announced he and his wife have covid-19 for the second time.

The congressman, who hasn't said whether he received a vaccine, referred to a conspiracy theory that the virus was intentionally engineered to be a biological weapon in a Facebook post announcing his illness.

“I have COVID, Becca has COVID, my son has COVID. Becca and I had COVID before, early on, in January 2020, before the world really knew what it was. So, this is our second experience with the CCP biological attack weaponized virus… and this episode is far more challenging. It has required all of my devoted energy,” he wrote.

“We are all under excellent care, and our prognosis is positive. We are very healthy generally speaking, and our treatment of any health concern always encompasses western, eastern, and holistic variables,” Higgins added.

OUCH: Experts are alarmed by China’s refusal of a new covid probe.

“Leading U.S. infectious disease experts are warning that China's rejection of a World Health Organization plan for another Covid-19 investigation inside the country threatens to deny the world critical data needed to identify and head off future pandemics,” Politico’s Phelim Kine, Carmen Paun and Ryan Heath report.

“We have had already two coronavirus pandemics come out of China and it’s more likely than not that we will have another coronavirus pandemic come out of China, so [a China-based probe] is our best chance to get our hands around how this gets out of bats and into humans,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. “We can’t do this without going to China. There is no way you can get to the bottom of this from 5000 miles away.”

Zeng Yixin, China’s vice minister of the National Health Commission, has rejected a second WHO probe that would audit relevant laboratories and research institutions operating in Wuhan, China, the city in which the first coronavirus cases were identified. The Chinese government has rejected the international focus on China as the origin of the pandemic, instead embracing a narrative that the virus had “multiple origins and broke out in multiple places.”

More in coronavirus news

GOP lawmakers are limiting public health powers.

“In some states, anger at perceived overreach by health officials has prompted legislative attempts to limit their authority, including new state laws that prevent the closure of businesses or allow lawmakers to rescind mask mandates,” The Post’s Frances Stead Sellers and Isaac Stanley-Becker report. “Some state courts have reined in the emergency and regulatory powers governors have wielded against the virus. And in its recent rulings and analysis, the U.S. Supreme Court has signaled its willingness to limit disease mitigation in the name of free speech.”

At least 15 states have passed or are considering measures to limit the authority of public health agencies, and lawmakers in 46 states have introduced hundreds of bills related to legislative oversight of gubernatorial or executive actions during coronavirus or other emergencies. One North Dakota law prohibits a mask mandate, even during a tuberculosis outbreak, while a new Montana law prohibits the use of quarantine to separate people who have likely been infected with a contagious illness.

Experts say these moves leave the country ill-equipped to counter the resurgent coronavirus and any future disease outbreaks. Even people who believe that the government may have overreached in some instances with the coronavirus, they argue, should be wary about tying the hands of public health officials in future pandemics.

  • Eight of the 20 largest school districts are making masks optional for children. An additional nine districts — including the three largest in New York, Los Angeles and Chicago — will require them. Only three of the largest districts remain undecided, CNN’s Elizabeth Stuart reports.
     
  • Low vaccine rates of nursing home staff put elderly residents at risk, the Hill’s Nathaniel Weixel reports. The spread of the delta variant is fueling renewed concerns because elderly individuals do not always respond as robustly to vaccines and may be at higher risk for breakthrough infections. Federal data shows that only around 59 percent of staff in nursing homes and long-term care facilities nationwide have received at least one coronavirus shot.
     
  • While top Republicans like Senate Minority Leader Mitch McConnell and Alabama Gov. Kay Ivey are pleading with Americans to get vaccinated against the coronavirus, other GOP officials have played down the threat of a coronavirus resurgence, Politico’s Adam Cancryn reports.
Alabama Gov. Kay Ivey (R) on July 22 blamed unvaccinated people for a recent spike in coronavirus cases in her state. (Reuters)
Trump's former press secretary is encouraging people to get vaccinated.

Sarah Sanders, who is running for governor in Arkansas, disclosed in an op-ed published yesterday by the Arkansas Democrat Gazette that she has received a coronavirus vaccine and urged others to do so as well. But she made clear it's because her doctor — and not President Biden or Fauci — said to get vaccinated.

“Based on the advice of my doctor, I determined that the benefits of getting vaccinated outweighed any potential risks," Sanders, who served as White House press secretary from 2017 to 2019, wrote. “I was also reassured after President Trump and his family were vaccinated. If getting vaccinated was safe enough for them, I felt it was safe enough for me.”

Sanders called Fauci “arrogant” and “condescending.”

“Like many of you, I have had a lot of misinformation thrown at me by politicians and the media during the pandemic,” she wrote. “What I found was simple: Dr. Fauci and the ‘because science says so’ crowd of arrogant, condescending politicians and bureaucrats were wrong about more than their mandates and shutdowns that have inflicted incalculable harm on our people and economy."

Elsewhere in health care

Illinois will make it easier to obtain birth control.

Gov. J.B. Pritzker (D) signed legislation on Thursday that will allow pharmacists to assess patients and provide them with hormonal birth control without a doctor’s prescription, the Hill’s Brooke Seipel reports.

“This legislation that I’m signing into law today makes Illinois one of the first states in the Midwest to provide birth control over the counter, making contraceptives all the more accessible and affordable in our state,” Pritzker said.

Illinois will join seven other states that offer birth control over the counter, including California, Colorado, Hawaii, New Mexico, Oregon, Tennessee and Washington.

Medicaid expansion is on again in Missouri.

The state Supreme Court ruled unanimously last week that the state legislature must fund the new program. State GOP legislators had blocked implementation funding after voters approved a ballot resolution calling for expansion, estimated to cover 275,000 people.

“The new ruling directs the lower court to work out the details of getting the new program underway, but it is unclear when exactly Missouri will begin enrolling patients,” the New York Times's Sarah Kliff writes. “Kelli Jones, a spokeswoman for Governor Parson, said in an emailed statement that the governor did not think he had the ‘necessary budget authority’ to implement the expansion, and was ‘looking at what options may be available.’”

Sugar rush