It’s an unfortunate ending for California patients – a utilization management bill successfully passed the state Assembly and Senate, just to be vetoed by Governor Gavin Newsom.
Sponsored by California Assembly member Dr. Joaquin Arambula, the bill would have required insurance companies to ensure that certain coverage denials are first reviewed by a relevant medical professional.
Wow, file that under “Things You Probably Thought Were Already Happening.”
The issue of the hour is utilization management – a fancy term describing how insurers evaluate the efficient use of healthcare procedures. In other words, insurance companies aren’t in the business of paying for just any treatment or service – they’re incentivized to approve the bare minimum of care, even if it’s insufficient for the patient’s needs.
Prior authorization is one method of utilization management, in which physicians have to secure approval by the insurance company before providing care. Another is step therapy, where insurers require patients to try lower cost versions of treatment before ‘stepping up’ to drugs that cost more. While fine in theory, this practice forces physicians and patients to follow a treatment plan essentially determined by an insurance company, regardless of the unique needs of the patient prescribed by doctors.
But here’s the thing – Arambula’s bill didn’t even attempt to tackle utilization management. All it did was require that if a patient filed to bypass step therapy, for example, and the insurance company denies the bypass, that the appeal must be reviewed by a medical professional with experience in the condition at hand.
That’s it. All it would do is give patients a little bit of their power back – a little bit more autonomy to work with a physician to determine which medications and procedures are going to be most effective for their care.
Because over and over again, we’ve seen insurers delay patient care under the guise of utilization management, and it’s ended in tragedy.
