On Nov. 3, Gov. Tom Wolf signed SB 225 into law. The new Act 146 of 2022 creates, via the Pa. Insurance Department, a defined process for both public and private insurers for medications and treatments that require insurer preauthorization. State Sen. Kristin Phillips-Hill (R-York) sponsored the bill, which received broad bipartisan support, including co-sponsorship by State Sen. Lisa Boscola (D-Northampton/Lehigh). Notably, the bill did not receive a single “Nay” vote in the General Assembly; it will go into effect in January 2024.

Prior authorization is the insurance requirement that a prescribing physician obtain a positive coverage determination from the insurer before putting a patient on a treatment plan. On her website, Sen. Phillips-Hill highlights a 2021 survey by the American Medical Assoc. (AMA) in which 82 percent of respondents said prior authorization sometimes, often, or always led to patients abandoning their recommended course of treatment.

Act 146 also states that medications for opioid addiction cannot be subject to prior authorization. Additionally, the law requires that the “peer review” process, in which an insurance company-employed doctor discusses a treatment denial with a prescribing doctor, be conducted by a physician in the same specialty as the prescriber.

Pennsylvania health care providers applaud the legislature for tacking an issue that has challenged both patients and providers, and are cautiously optimistic that the bill will improve the provision of health care in the state.

Dr. Jonathan Hosey, chairman of neuroscience at St. Luke’s University Health Network and member of the board executive committee of the American Academy of Neurology, described challenges that have faced practices. In his own specialty of neurology, for example, migraine is a common reason for patients to seek care. In the early years of pharmacological therapy for migraines, some drugs were commonly used; however, those drugs have since been surpassed in efficacy and side effect profiles by newer agents that specifically target migraine receptors.

Some insurers, however, require a “stepwise,” or “fail first,” approach to therapy; in other words, the newer drug is only covered by insurance after the patient has “failed” therapy with older drugs. Both demonstrating that a stepwise approach has been used and appealing administrative coverage denials consume large amounts of time and effort, including by clinically trained personnel such as doctors and nurses. And all too often, the physician at the insurance company taking part in the “peer review” process is not licensed in the specialty of the physician treating the patient and lacks the background to have a productive discussion.

Hosey notes that working on prior authorization “takes providers away from direct patient care or provision of care to work on the successful advocacy of gaining authorization from an insurer.” Although he notes that “it’s too early to tell what impact [the law] is going to have,” he lauds the fact that “it does define a process now that’s going to be universal for insurers to follow, and with that process, we on the provider side have a better road map of what our patients’ rights are, and what is available for us representing our patients to advocate for.”

Hosey also celebrates the passage of the law, remarking that “legislators in this case are really looking at the issues that frustrate providers, and could most benefit our patients. It’s a very positive message that the combined legislature sent to Pennsylvanians.”

Boscola backed the bill from its origins in the Senate Banking and Insurance Committee through the final vote.

“I am proud to have supported the needed reform of prior authorization for medical services this past legislative session,” Boscola said. “Medical services will now be better streamlined to eliminate wait times for patients and doctors alike. Also, reducing administrative costs for hospitals and health care providers is another vital component of the new law. Furthermore, these changes to the prior authorization will have minimal impact on taxpayers because the Pennsylvania Department of Health already has the budget capacity to accommodate the reforms made in Act 146.”