Physicians would have greater leeway in prescribing medications to patients, and insurance companies would have less time to approve prior-authorization requests under a bill unanimously approved by a Senate panel Tuesday.
But bill sponsor Greg Steube, R-Sarasota, told senators that if they would like to see the proposal (SB 98) make it into law, they need to press the House of Representatives — which, he said, killed a similar measure last year.
The bill would amend current law to require health insurers, HMOs, Medicaid managed-care plans and pharmacy benefit managers to approve or deny prior-authorization requests in urgent circumstances within 24 hours of receiving the requests. In non-urgent situations, companies would have three days.
The timelines are shorter, for example, than what's currently allowed in the state-employee health insurance program and in the Medicaid program.
HMOs and insurance companies that participate in the state group program are contractually required to review urgent or emergency prior-authorization requests within 24 hours after receipt and within 14 calendar days after receiving routine requests.
Meanwhile, according to a staff analysis, Medicaid officials said they would have to amend managed-care contracts to change prior-authorization requirements and utilization-review timeframes.
Currently, Medicaid managed-care contracts require health plans to authorize or deny standard requests for prior authorization for services other than prescribed drugs within seven days and authorize or deny expedited requests within 48 hours.
Prior authorizations for prescription drugs must be handled more swiftly; the plans must deny, approve or seek additional information within 24 hours after receiving requests for prior authorization for prescription drugs.
According to the staff analysis, the bill would “significantly affect the business (staffing, systems, etc.) and clinical operations of the Medicaid managed care plans. The bill requires the plans to shorten the time to review authorizations, which will increase the administrative costs.”
However, the staff analysis stopped short of putting a price tag on the changes, noting that the increased costs in the Medicaid program and the state group health plan are “indeterminate.”
The bill was supported by groups such as the Florida Medical Association, the Florida Osteopathic Medical Association and AARP Florida. It has widespread support in the Senate, which unanimously passed a similar proposal last year.
Senate Banking and Insurance Committee member Doug Broxson, R-Gulf Breeze, said he has seen similar legislation over the last several years and asked Steube: “Why didn't it pass last year, and what would we have to do to make sure this gets on the governor's desk this year. Where's the hang up?”
Steube said the bill died last year in the House Health and Human Services Committee and half-jokingly told members, “I encourage you to talk to Chair (Travis) Cummings,” who leads the House committee.
Broxson, though, pressed Steube, asking him if the Senate was “positioning itself to do this every year, to vote on something that is not going to be heard in the House or be seriously considered?”
Steube then struck a serious tone, saying he's been told Cummings, R-Orange Park, may be “more open to looking at it this year” but said he hadn't had the opportunity to speak with the House chairman about the bill. The bill is filed for the 2018 legislative session, which starts in January.
In addition to addressing prior authorization requirements, the bill also would create a new section in insurance law to address “step therapy” or “fail first” protocols used by insurance companies, HMOs and pharmacy benefit managers. The protocols prescribe certain medical procedures, prescription drugs or courses of treatments that must be used to treat conditions.
Natalie Blake, director of program services for the Multiple Sclerosis Foundation, told senators that “it's unconscionable for somebody with a disease like multiple sclerosis to have to fail a drug first. They should be allowed to take any drug that their physician approves for them that is approved,” by the Food and Drug Administration.
“In MS, if you fail a drug, it results in further disability. You have more progression of your disease and in the long run, it results in a lot more costs to the health system,” she said.
But insurers said the bill would curb the effectiveness of the protocols by requiring insurance companies to approve providers' requests for exceptions under certain criteria. Exceptions would be required, for instance, if a treatment is expected to worsen a patient's medical condition or decrease the ability of the patient to perform daily activities.
Audrey Brown, president of the Florida Association of Health Plans, was the sole lobbyist to speak against the bill Tuesday.
She told the panel that prior authorization and step therapy requirements serve a two-fold purpose: to save costs and to ensure patient safety.
“Half of over every dollar spent by the pharmaceutical industry is on direct consumer marketing, which increases a patient's demand for high-cost brand drugs,” she told the committee. “Requiring the step of a generic equivalent is one of the only negotiating tools a health plan has over costs.”
Brown also touched on Florida's opioid crisis in her testimony, noting that requiring patients to take non-addictive opioid alternatives before narcotics helps curb potential overprescribing.