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Will reducing prior authorization help or hurt the state’s health care system?
(Credit: Maudib)
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.”
What’s next?
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.
Contact Kaitlin Lange on X @kaitlin_lange or email her at [email protected].
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Indiana appeals court chief judge on AI, mental health, and the state’s dwindling number of lawyers
Many Hoosiers may be familiar with their local courts or hear about the opinions of the Indiana Supreme Court, but a middle tier in the state’s judiciary system shapes justice through some 2,000 rulings a year.
The 15 judges of the Indiana Court of Appeals dole out opinions on everything from murder and fraud to civil and child welfare cases. Every Hoosier has the right to appeal a conviction or ruling, and the Court of Appeals, the second-highest court in the state, takes up each case sent its way.
Chief Judge Robert R. Altice Jr. has analyzed thousands of cases since being appointed by Gov. Mike Pence in 2015. Prior to that, he spent 15 years as an elected judge in Marion County.
Altice sat down with State Affairs for a discussion on the ins and outs of his court, how changes in technology and mental health care have impacted his work and what he sees as a major problem facing the nation’s judicial system.
This conversation has been edited for clarity, brevity and length.
Q. What sort of cases does the Court of Appeals hear?
A. We hear really everything except death penalty cases. If there’s a death penalty case, it goes straight to the [state] Supreme Court. Otherwise, we get it.
I’ve had to publish an opinion on a traffic court case. About 65% of our cases are criminal. Every, everything under the sun: murders, rapes, robberies, child molestation.
Then there are civil cases. We do medical malpractice suits, traffic accidents, you name it. Complex business litigation? Our court was involved.
Q. How does the appeals process work? There’s not a new trial, right?
A. I’ll give you an example. Let’s say you got a murder case and the defendant gets convicted and gets 65 years, which is the max for a murder conviction. Everybody in the state of Indiana has got an automatic right to appeal. Not everybody takes that right, but most criminal defendants do.
Somebody will write his brief for him. That attorney will find three issues that they think will result in a new trial if we rule in their favor. That’s really what the appellate process is: Are the errors committed at the trial court level significant enough to warrant a new trial?
And then the attorney general in the criminal cases will write a brief in opposition, then the appellant or the defendant can file a reply brief as well.
We sit and read transcripts and their briefs and do our own research and come to a decision as to whether or not there was error at the trial court level that warrants a new trial.
Q. How many of the 2,000 cases your court receives a year, how many are taken up by the Indiana Supreme Court?
A. It is rare. You start with the proposition that trial courts throughout the state are doing about 2+ million cases a year. That’s everything. We do 2,000 opinions a year. I think the Supreme Court writes about 60 opinions a year. That’s what their taking of ours.
But we’re considered an error-correcting court, whereas that’s really not their role. Their role is more jurisprudential. It’s “should we look at changing in this regard or changing precedent.”
It’s really an inverse pyramid, with the trial courts, I always say, doing the heavy lifting.
Our turnaround time is very quick. It’s about three months. Some states require oral arguments in every single case, but we don’t.
If you ask for an oral argument, we will sometimes grant that. We do a lot of oral arguments, but most of our oral arguments are traveling oral arguments. We travel all over the state and do live arguments. And we do those in front of high schools, small colleges, bigger schools.
We answer questions or ask questions like we normally would do, and then once we’re finished, then we have a question and answer session with the students.
Q. One thing we heard about at the State of the Judiciary is there’s an attorney shortage in the state, particularly in rural areas. How has that affected your work?
A. I think we’re seeing more pro se litigants, people representing themselves, and that can be difficult because we hold them to the same standard that we would hold a lawyer to. It can be really difficult for them. So in that regard, it has hurt.
We’ll go to traveling oral arguments in some rural county, and the bar association will host a lunch for us. We’ll go and there’ll be six lawyers in the room and I’ll say to somebody, “So how many people are in the bar?” And they’ll say, “Well, you’re looking at it.”
That access to justice is a really difficult thing that I think the state of Indiana is dealing with now. The Supreme Court has just set up a task force to look into how we can improve that. I believe law schools are looking at incentivizing young kids to go practice in rural areas.
It’s a real issue. I think a lot of it stems from the low bar passage rate of the last 10+ years. It’ll be interesting to see what the task force thinks.
Q. How has technology impacted the court?
A. Technology has been huge. All our work is done online now. The briefs are filed online.
The technology that we have to keep an eye on, and we’re already looking at, is artificial intelligence. What impact is that going to have on the courts, especially our courts?
You can punch a button and write an opinion. It’s probably not going to be very good, but as technology improves, it’s going to be. We’re kind of leery of that.
But at the same time, from a research standpoint, it’s been a very valuable tool. We’ve been using AI in that regard for researching for some time now, with Westlaw and Lexus as they’ve come out with those kinds of tools.
Q. There have been changes in how the world views mental health. How has that impacted the court?
A. I see it primarily in the sentencing arena. Before every defendant is sentenced by a trial court, a pre-sentence investigation is prepared on them. And so that’s where you see a lot of that because it discusses their entire background, and the number of people with mental health issues coming through has really increased greatly.
I think the pandemic had a lot to do with that as well. But again, the mental health issues are very much creeping into the system, and one of the things that we’re constantly working on trying to be aware of and trying to, to the extent we can with alternatives to incarceration, assist people.
Q. Are there any other challenges facing today’s judiciary?
A. I guess not necessarily my court, but courts in general. It appears to me that Congress is broken. They’re not passing laws.
So, what are we doing? We have to rely on the other two branches of government to kind of take up the slack, and that’s why you’re seeing tons of executive orders.
That’s not traditionally their job, and then you’re seeing the courts being called upon to determine whether or not those regulations are enforceable.
I see that as a long-term problem that we’ve got to get corrected.
Contact Rory Appleton on X at @roryehappleton or email him at [email protected].
How McCormick, Braun view abortion, taxes and other key issues
A Democrat-turned-Republican and Republican-turned-Democrat will soon face off in the race to become Indiana’s next governor.
Sen. Mike Braun, who voted as a Democrat prior to 2012, captured the Republican nomination in Tuesday’s primary. Jennifer McCormick, formerly a Republican Superintendent of Public Instruction, will represent the Democrats.
Voters will decide the state’s next chief executive in November.
A State Affairs analysis of the candidates’ campaign platforms and public statements found key differences — and a few similarities — in their planned approaches to a variety of issues impacting Hoosier voters.
Here is how they match up.
Abortion
Braun: As a senator, Braun has long supported abortion restrictions.
In 2020, he called for the Supreme Court to re-examine Roe v. Wade.
In 2023, he proposed federal legislation that would have required parental notification before any unemancipated minor could seek an abortion. He said at the time: “Hoosiers put their trust in me to stand up for the unborn, and that’s what I’ve been proud to do every day in the Senate.”
He has since signaled support for the state’s abortion ban. His platform reads: “State lawmakers must work to ensure the gains we have made to protect life are secured and strengthened.”
McCormick: In a Tuesday interview with State Affairs, McCormick said her candidacy represented a referendum on reproductive rights.
“I’m going to fight to restore those rights under any authority I can, working in a bipartisan fashion, using our committees, board and our agencies. I also know, too, what everybody’s fear is: that they’re [Republicans] not going to restore those rights and will take [restrictions] further.”
From her platform: “Indiana’s Republican-led extreme abortion ban has taken away the right of women to make deeply personal decisions regarding their own health care.”
Marijuana
Braun: At a March 26 Republican primary debate, Braun suggested an openness to legalizing medicinal marijuana.
“It’s gonna hit all of us. I’m gonna listen to law enforcement — they have to put up with the brunt of it,” he said. “Medical marijuana is where I think the case is best made that maybe something needs to change. But I’ll take my cue from law enforcement there as well. … I hear a lot of input where [medical marijuana is] helpful, and I think that you need to listen and see what makes sense.”
McCormick: The Democrat’s platform also addresses medical marijuana legalization, while speculating on possible recreational use.
“We will fight for the legalization of medical marijuana as a source of state revenue established on a well-regulated marketplace and monitored by a Cannabis Task Force in order to study the issues, opportunities and potential obstructions associated with recreational marijuana legalization.”
McCormick said she would also support expunging low-level marijuana-related convictions.
Taxes
Braun: At a March 19 National Federation of Independent Business forum, Braun said the state’s property tax system “went out of whack because it couldn’t respond to inflation like we’ve never seen before.”
“The way you finance any lower taxes would be to bank on the government being run more efficiently,” he said.
His platform also calls for government spending cuts to finance lower taxes: “Reducing the size of government is the key to cutting taxes, and Mike Braun will work through every state agency to find ways to save money while delivering high-quality services to taxpayers.”
McCormick: McCormick also spoke about taxes at the March 19 forum.
“I agree with a revamp of our taxing system,” she said. “But also it’s about not just how we’re getting our revenue, it’s about our expenditures. Yes, we need to fix our gas tax. Yes, we need to look at the income tax. But here’s the thing: There are hidden taxes we’re not having a conversation about.”
Her platform also references the possibility of combining state agencies as a way to save money.
Education
Braun: In his platform, Braun supports broadening school choice and parental rights.
“As a former school board member, Mike Braun knows parents are the primary stakeholders in their children’s education and every family, regardless of income or zip code, should be able to enroll in a school of their choice and pursue a curriculum that prepares them for a career, college or the military,” the platform reads.
Braun also pledged to ensure critical race theory and discussions about gender are banned in public schools.
McCormick: Education is one of McCormick’s primary issues, according to her platform.
She calls for the elimination of statewide testing, increased early childhood reading and child care options and a minimum base salary of $60,000 for all K-12 teachers.
McCormick also addresses the state’s school choice movement.
“We will call for a pause in the expansion of school privatization efforts while requiring fiscal and academic accountability and transparency for all of Indiana schools that receive public tax dollars,” her platform reads.
U.S.-Mexico border
Braun: Braun’s television ads have touched on border security, and his platform calls for increased focus on the area.
“Joe Biden and the left have created a humanitarian and national security crisis on our southern border,” the platform reads. “As governor, Mike will continue to support and enact the America First policies that were working. Otherwise, every town will become a border town.”
McCormick: McCormick’s border-related plans are more focused on facilitating legal immigration.
“We will work with local, state and federal officials in supporting an immigrant system that creates a safe, timely, orderly and humane pathway for those seeking legal immigration while keeping our communities and those responsible for border security safe,” her platform reads.
Contact Rory Appleton on X at @roryehappleton or email him at [email protected].
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