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Will reducing prior authorization help or hurt the state’s health care system?
When Dr. Elizabeth Struble thinks a patient has a kidney stone, she often sends them home with some medication and contacts insurance to order a CAT scan.
But it can take insurance providers up to five days to approve the scan. Meanwhile the patient’s symptoms can continue to worsen, and eventually some patients might need to be admitted to a hospital because they became ill or septic.
“This is a common story, ” the family medicine doctor from North Manchester said during a committee hearing on the bill. “This happens all the time.”
Struble and other physicians say delays due to prior authorization requirements — when health care providers need to obtain approval from insurance companies before issuing care — are limiting their ability to treat patients quickly and properly. However, insurers say nixing prior authorization requirements could increase unnecessary procedures and, as a result, health care costs.
Indiana lawmakers are grappling with those conflicting messages while they consider Senate Bill 3, which would significantly restrict when insurance providers can require prior authorization for medical care.
“The original idea behind prior auth was that it could contain health care costs,” said bill author Sen. Tyler Johnson, R-Leo. “What we see every day is that prior authorization has become a huge hurdle to patients getting the care they need.”
The proposal has passed out of one legislative committee but must clear one more before the full Senate can vote on it.
In a testament to the complexity of the debate, the bill was pulled from the Senate Appropriations Committee calendar Thursday over concerns that decreasing prior authorization requirements could fiscally impact the state, Senate President Pro Tem Rodric Bray said.
“We’ll take a look at that,” he said, “and hopefully get to the hearing next week.”
What Senate Bill 3 does
Under Senate Bill 3, insurance providers could not require prior authorization for emergency services — such as when someone needs their appendix removed — routine care and prescription drugs.
It would also prohibit insurance companies from requiring prior authorization on more than 1% of services and give health care providers a yearlong break from prior authorization requirements if their prior authorization approval rating the previous year was above 80%.
That so-called gold card policy is similar to those passed in West Virginia, Texas and Louisiana.
The procedures or drugs that still would require prior authorization would need to be reviewed by a physician, meaning insurance companies couldn’t use just a computer algorithm to decide who doesn’t get care.
“The patient needs to be at the center of this discussion,” said Johnson, an emergency room physician. “It’s really easy to see that [prior authorization] puts a big burden in front of a patient getting care, and that’s a huge administrative cost.”
So what would reducing prior authorization mean on a practical level for Hoosiers?
It could help those who have kidney stones or need physical therapy.
Jason Hazelett, the owner of Steppin’ Up Physical Therapy in Fort Wayne, said he had a patient whose leg was partially amputated and was ready to begin therapy after getting a prosthetic leg so that he could relearn how to walk. Throughout physical therapy, Hazelett’s company had to keep seeking prior authorization for additional physical therapy sessions, leading to long gaps in care.
“This gentleman is getting set back during that time there was no therapy,” Hazelett said, ”not because we couldn’t see him, but because we were waiting on a peer review or prior authorization to come back.”
Dr. Elizabeth Wright, chief ambulatory officer at Hendricks Regional Health, brought up another scenario in which a patient had severe lower back pain. She said the patient needed advanced imaging, but because she had to seek prior authorization first, that care was delayed.
“That delay led to chronic pain which could have been prevented if we had initiated treatment sooner,” Wright said. “These are things that we run into every day.”
She added that her office staff spends hours daily working on prior authorizations.
It’s not just an Indiana concern. According to a 2022 American Medical Association survey, 33% of physicians reported that prior authorization has led to “a serious adverse event” for one of their patients.
Does prior authorization increase or decrease health care costs?
Insurance providers and business representatives often say that prior authorization helps keep health care costs lower. But it’s unclear whether a net economic benefit to prior authorization exists.
A 2019 report from Altarum’s Center for Value in Health Care found that studies show mixed results on the impact of prior authorization. There’s been no combined cost-benefit analysis, the report authors said.
“[Prior authorization] can reduce avoidable care while helping to control health care expenditures,” the report authors wrote. “On the other hand, the process imposes time and cost burdens, can result in delays in needed care, and causes confusion and often frustration for providers and patients.”
The Indiana Chamber of Commerce and the Indiana Manufacturers Association opposed Senate Bill 3 over concerns it could increase health care costs for businesses.
“Let’s not mistake the occasional hiccup that we’ve heard about today as a problem with the system’s fundamental value,” Ashton Eller, vice president of health care policy and employment law for the Indiana Chamber of Commerce, said during a committee hearing on the bill. “The prior authorization process is a tool in the employer’s toolbox to help contain health care costs.”
A legislative fiscal analysis of the bill warns that the state — an employer itself — could have to pay more money if a decrease in prior authorization leads to state employees or Medicaid users accessing more medical care.
Blaire Hadley, director of government relations for Insurance Institute of Indiana, said her organization is open to discussing strategies for improving prior authorization but emphasized that the tool ensures patients get the right care at the right time in the right place.
“We know this process is not perfect,” Hadley said. “However, we are committed to working with all of you and with the market, with providers and hospitals, while also keeping in mind what our employer partners are asking for.”
Like most legislation targeting health care costs, the bill faces strong opposition and could be challenging to push across the finish line. The business community and those in the health insurance industry — both powerful lobbying groups at the Statehouse — have concerns about the legislation.
Last year many of Republicans’ attempts to pass meaningful bills targeting health care costs were watered down before their final passage.
The deadline for the bill to make it out of the Senate Appropriations Committee is Thursday. A committee agenda for this week has not been released yet.
Senators rejected a proposal Monday to remove strict limitations on what legal research Indiana’s public access counselor could consider in reviewing open government matters. That means House Bill 1338 could face a full Senate vote on Tuesday with provisions that supporters of the access counselor’s office argue would hamstring its ability to answer questions about …
Indiana doctors performed fewer than four abortions a week during the final three months of 2023, continuing the sharp downturn under the state’s near-total abortion ban.
Doctors reported 46 abortions from October through December, according to the state Department of Health’s latest quarterly report on abortions.
The ban that took effect in August allows abortions only in cases of rape or incest before 10 weeks post-fertilization or to protect the life and health of the mother or because of a lethal fetal anomaly up to 20 weeks of pregnancy. It also voided the state licenses of all Indiana abortion clinics, allowing abortions only in hospitals or hospital-owned surgery centers.
Of the abortions reported during the fourth quarter of last year, 22 were because of lethal fetal anomalies, 21 were attributed to health risks to the pregnant woman and three were due to rape or incest, according to the state report released last week.
The 46 abortions during the fourth quarter represented a 97% drop from the 1,724 reported during the same three months in 2022 while the abortion ban was blocked by a judge’s order later overturned by the state Supreme Court.
Indiana Right to Life, the state’s most prominent anti-abortion group, hailed the decline but joined criticism of the Department of Health for not releasing individual terminated pregnancy reports as it had done before the ban went into effect.
The agency has said it no longer releases those reports under state law that declares medical records confidential because of more detailed information required from doctors.
“The Indiana Department of Health is blocking public access to terminated pregnancy reports,” Indiana Right to Life President Mike Fichter said in a statement Monday. “This manipulation creates a lack of transparency, making it impossible to verify these numbers are accurate — and that Indiana law is being followed related to abortion activity.”
Abortion-rights supporters have argued that the ban wrongly limits access to health care. They’ve also maintained that abortion care would largely be unavailable outside Indianapolis even in situations meeting the limited exceptions, with the procedure no longer available at abortion clinics.
All but two of the 46 abortions during the reporting period were performed at Indianapolis hospitals, with the most at Riley Health Maternity Tower (21) and Eskenazi Hospital (10). The only hospital-performed abortions outside Indianapolis were one each at Dupont Hospital and Parkview Regional Medical Center, both in Fort Wayne.
The Senate has backed off a proposal that would block lawyers who’ve faced recent serious misconduct sanctions from running for state attorney general. A Senate committee had added a provision to an elections-related bill last week as Republican Attorney General Todd Rokita remains under scrutiny from the state’s attorney disciplinary commission after being reprimanded by …
The scope of what Indiana’s public access counselor could consider in reviewing open government matters would be strictly limited under provisions added to legislation in the closing days of the legislative session.
Amendments that a Senate committee made this week to House Bill 1338 would also reduce the office’s independence by eliminating the four-year term the access counselor has after being appointed by the governor.
The Legislature in 1999 established the access counselor position to review questions from the public, government officials and others about the state’s open meetings and public records laws.
The public access counselor’s office, with two attorneys and one other staff member, issues dozens of advisory opinions each year but has no authority to enforce the access laws or punish violators.
Advocate says amendment ‘guts’ counselor’s authority
Sen. Aaron Freeman, R-Indianapolis, offered the amendment allowing the access counselor’s advisory opinions to consider only “the public access laws, as plainly written,” and “valid opinions of Indiana courts.”
Freeman, chair of the Senate Corrections and Criminal Law Committee, expressed frustration with Public Access Counselor Luke Britt’s opinions without giving specifics during the Tuesday meeting when the provision was added.
“The public access counselor, it says that he, in this case, shall liberally construe the code,” Freeman said. “He’s issued some opinions that I vehemently disagree with and I think others in our body and in this building vehemently disagree with.”
The amendment “functionally guts” the access counselor’s ability to consider the context of a situation unless it has been directly addressed by the Legislature or court, said Amelia McClure, executive director of the Hoosier State Press Association.
“The code can never contemplate all of the different circumstances that public access concerns are going to arise,” McClure said. “So the public access counselor has to consider new technologies, what location, the circumstances of the conversation in a way that a civil code will never be able to contemplate.”
Britt was appointed access counselor in 2013 by then-Gov. Mike Pence and reappointed by Gov. Eric Holcomb in 2017 and 2021.
Britt, whose current term runs until Oct. 31, 2025, declined to comment to State Affairs on Freeman’s amendments. The governor’s office didn’t immediately reply Thursday to a request for comment.
The restrictions on the access counselor’s office were not raised during the first seven weeks of this year’s legislative session and became public only two days before the Senate committee’s deadline to take action.
Public access counselor’s role at issue
Some conservatives criticized an opinion Britt released last fall in which he concluded the Hamilton East Public Library Board in Fishers violated the open meetings law when two board members met with their attorneys at a coffee shop.
That opinion came amid public debate over a push by conservative members of that board to review all youth-section books and move those with “inappropriate” content to adult sections.
The opening section of Indiana’s public records law states it should be “liberally construed to implement this policy and place the burden of proof for the nondisclosure of a public record on the public agency that would deny access to the record.”
Freeman said during the committee meeting that he favored striking the “liberally construed” phrase from the law, but other senators thought that went too far.
The amendment limiting the access counselor’s authority was added to the bill on a 5-3 vote as Democratic Sen. Greg Taylor joined Freeman and other Republicans Mike Bohacek, Cyndi Carrasco and Eric Koch. Republicans Liz Brown and Sue Glick and Democrat Rodney Pol voted against the amendment.
Glick said the restriction on what the access counselor could consider didn’t make sense.
“You’re paying an attorney for their opinion, and now you’re limiting that,” Glick said.
Change would eliminate term of office
Freeman also advocated for an amendment eliminating the access counselor’s four-year term and making the position one that serves “at the pleasure of the governor.”
“When we have a new governor … I believe the governor should be able to pick the person that they’re choosing to serve,” Freeman said. “As any other appointed office, we serve at the privilege of the governor. So I believe this should be no different.”
Those people appointed to lead state departments can typically be removed at the governor’s discretion. However, hundreds of appointments to state boards and other positions, such as the state Election Division’s co-directors, are made for set terms.
McClure, the Hoosier State Press Association’s director, said eliminating the four-year term would take away some of the office’s independence from political concerns.
“That’s important when it’s an advisory opinion that’s interpreting actions of all kinds of different bodies that have all kinds of different political affiliations,” McClure said.
The full bill, which initially focused only on allowing local government boards to establish meeting decorum rules, could be taken up by the full Senate next week. The additions would still also need approval from the House before this year’s legislative session ends by March 14.