Dear Honorable Members of the House Health and Social Services Committee:
On behalf of the approximately 60 people with cystic fibrosis in Alaska, we write to express our support for HB 187, which would streamline prior authorization (PA) requirements by creating an automatic exemption for physicians for whom the vast majority of their PA requests are approved. PAs can delay access to critical CF therapies and the Cystic Fibrosis Foundation supports efforts to minimize the administrative burden PAs impose on patients and their providers, enhance efficiency of the process, and promote transparency of PA requirements. We urge you to support HB 187 to ensure immediate and consistent access to critical therapies for Alaskans with CF.
About Cystic Fibrosis and Prior Authorizations
here are close to 40,000 children and adults living with cystic fibrosis in the United States, and CF can affect people of every racial and ethnic group. Cystic fibrosis is a life-threatening genetic disease that causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, which can lead to life-threatening infections. Cystic fibrosis is both serious and progressive; lung damage caused by infection is irreversible and can have a lasting impact on length and quality of life. As a complex, multi-system condition, CF requires continuous targeted, specialized treatment and medications. While advances in CF care are helping people live longer, healthier lives, we also know that patients often encounter barriers to accessing them.
Prior authorizations are one of the obstacles that people living with chronic conditions, including CF, must navigate when accessing care. Time consuming PA requirements can delay the start or continuation of needed treatments, which can lead to adverse health outcomes. In a 2022 survey by the American Medical Association, 94% of physicians reported that prior authorizations led to delays in necessary care for their patients whose treatment required PA and 80% reported that PAs have led to patients abandoning their treatment at some point. Because CF is a progressive disease, patients who delay or forgo treatment — even for as little as a few days — face increased risk of lung exacerbations, costly hospitalizations, and potentially irreversible lung damage.
Prior authorizations are one of the obstacles that people living with chronic conditions, including CF, must navigate when accessing care. Time consuming PA requirements can delay the start or continuation of needed treatments, which can lead to adverse health outcomes. In a 2022 survey by the American Medical Association, 94% of physicians reported that prior authorizations led to delays in necessary care for their patients whose treatment required PA and 80% reported that PAs have led to patients abandoning their treatment at some point. Because CF is a progressive disease, patients who delay or forgo treatment — even for as little as a few days — face increased risk of lung exacerbations, costly hospitalizations, and potentially irreversible lung damage.
Gold Carding
To reduce administrative burden and delays in care, HB 187 exempts providers from PA requirements if 80 percent of their requests were approved in the preceding 12 months — a practice known as gold carding. Once providers obtain an exemption, they would be exempt from having to request PAs for that healthcare service for at least the next year. Because cystic fibrosis requires highly specialized care and treatment, the vast majority of people with CF receive care at a CF Foundation-accredited care center — which provide quality, specialized CF care that is based in clinical guidelines. If members of a CF care team received an exemption, that care center could spend more time on patient care instead of paperwork and, most importantly, people with CF could avoid delays in care.
CF care consists of numerous chronic specialty medications with strict prior authorization requirements and there are many instances of initial denials of clinically appropriate prior authorization requests. For instance, prior authorization criteria can vary from plan-to-plan and even year-to-year within the same plan; physicians are required to frequently adapt to ever-changing prior authorization requirements for the same medication and may incorrectly fill out the PA forms as the requirements change. Additionally, there is a lag between label expansions, which make more individuals eligible for a given therapy, and payer coverage for new populations — meaning physicians sometimes submit clinically valid requests that are denied because coverage policies have not yet been updated. Further, on occasion, payers put clinically inappropriate prior authorization coverage criteria in place for CF medications.
The Foundation urges the committee to amend HB 187 to specify how a prior authorization request that is initially denied but subsequently approved upon appeal will contribute to a prescriber’s approval rate. As mentioned above, there are multiple factors that could lead to an initial denial of a CF therapy that is clinically appropriate for a patient and ultimately approved. Therefore, only the final prior authorization decision, regardless of any initial denial, should count towards a prescriber’s approval rate. By doing so, this committee will ensure that gold cards are granted to physicians with a proven track record of appropriate care and treatment and that they physicians are not penalized for administrative errors or payer error unnecessarily.
The Foundation appreciates that PA policies were adopted to ensure patients only receive medically necessary care, and we understand the challenge insurers face in managing medication utilization and cost. However, utilization management cannot come at the expense of delays in patient access to needed care. HB 187 provides an opportunity to make prior authorization processes more transparent and efficient, allowing for timely access to appropriate treatments.