Lawmakers are trying to reform an insurance practice aimed at curbing unnecessary treatments called "prior authorization” — when health care providers need approval from insurers before delivering medical services or medications.
“Prior authorization was the number one complaint for physicians in terms of being both a huge administrative burden for them as well as making them feel like they couldn't give their patients the quality of care that they were trained to give their patients,” state Rep. Lisa Marten said.
She introduced one of the bills taking the first steps to reform prior authorization.
Physicians in Hawaiʻi, and across the country, have raised concerns that the policy is making it difficult for many people to get medical services. They say the administrative burden is impacting their ability to deliver care.
Dr. Jerry Garcia, a double board-certified pain specialist with the Hawaii Medical Association, explained that he wouldn’t have an issue with prior authorization if it were just for the more extensive procedures. However, even routine procedures now require it.
“Even small procedures like trigger points and joint injections now require prior authorization. In the past, you just put some cortisone in the knee or shoulder and provide the patient with almost immediate pain relief,” he said.
“Now the patient has to wait two weeks before it gets approved – and oftentimes it's not going to automatically get approved because they want more information. More than denying, it's really more delaying.”
The Hawaii Medical Service Association, the state’s largest insurance provider, approved 90% of prior authorization requests in 2024. Nationally, 83% of denied prior authorization requests were overturned in 2022.
No industry standard for which services require prior authorization
An HMSA patient could require prior authorization for a procedure, but another patient in the exact same situation with a policy at University Health Alliance does not.
Hawaiʻi Island Community Health Center Medical Director Chris Piel explained that health care providers struggle to keep up with the different standards each insurance company uses to determine which medical services and medications require prior authorization.
“They don't know which standards they're going off of, and they might not be based on the most current standards. They might just be based off maybe what's the most restrictive,” he said.
“I think that's really challenging to just keep up with – what are your technical administrative requirements around submitting this and then what are your clinical guidelines?”
Hawaiʻi Public Radio spoke with doctors who said services like MRIs, CT scans, blood tests, and even diabetes medications have required prior authorization from insurance companies.
HMSA posts a list on its website of the many services that require prior authorization.
Considerable time and staff to complete prior authorization process, doctors say
The University of Hawaiʻi John A. Burns School of Medicine Area Health Education Center surveyed about 100 physicians statewide to better understand the impact of prior authorization.
It found that doctors and their staff spend about 20 hours a week on average exclusively working on prior authorizations.
Physicians and their offices fill out paperwork providing information to insurance companies about why a medical service is necessary. Then sometimes the doctor will need to get on the phone with the insurance’s doctor to do what’s called a peer-to-peer review.
“It's maddening to try and break out of your clinical interactions so that you can have a peer-to-peer view,” said Dr. Elizabeth Ann Ignacio, an interventional radiologist and the president of the Hawaii Medical Association.
Sometimes the doctor on the other end of that review is not the same specialty, further complicating the process. Ignacio explained that she has had to justify why a particular exam is needed over other easier ones — something a doctor in her specialty would understand.
“You're trying to explain to them, ‘That won't work, that won't answer the question,’” she said. “It takes so long, and it's frustrating when you think that if we spend this much time every day and every week, automatically that's subtracting time from our patients, and ultimately that is what really wears and tears and burns out our providers.”
According to the American Medical Association, 95% of physicians attribute prior authorization to physician burnout.
Impacts to patient care
Dr. Kaʻohimanu Dang Akiona, a family physician with ʻAhahui o nā Kauka, the Association of Native Hawaiian Physicians, said patients have abandoned care because of the wait time for prior authorization.
Other patients, particularly those in pain, will instead just go to the emergency room.
“I don't recommend [it], but out of frustration, when the pain is getting worse, a lot of times they end up going, and 100% could have been prevented if we just kind of had a better process to address their concerns in a timely way,” Akiona said.
“It affects how they engage with the health care system. It has over time affected their trust in kind of how things are going to happen. And it definitely has impacted our ability to do our job.”
The JABSOM survey found that 90% of doctors said prior authorization resulted in people not adhering to a treatment plan; 40% reported that it resulted in a serious adverse event for a patient.
On Hawaiʻi Island, interventional radiologist Ignacio was treating a cancer patient who was waiting for prior authorization on an oncology drug regimen that would have required travel to Oʻahu.
In the end, the patient decided they did not want to wait — and gave up on the treatment.
“She was just like, ʻForget it. It's taking too long. Can you please just give me this other alternative?’ which was not going to be the best choice, but she just wanted to start something,” Ignacio said. “She didn't get the care that she should have gotten, and that was heartbreaking.”
Reforms to prior authorization considered at the Legislature
HMSA Vice President Dr. Stefanie Park wrote in an email that prior authorization is a practice to keep health care premiums affordable.
“It’s important for HMSA to balance access and affordability… Our efforts aim to reduce and prevent waste and abuse, help to ensure the long-term sustainability of Hawaii’s health care system,” she wrote. “We’re modernizing our processes and reevaluating the effectiveness of current practices.”
Boston University public health professor David Rosenbloom was part of the creation of prior authorization in the 1980s. He has since advocated for reforms.
Rosenbloom explained that many of the studies on whether prior authorization actually helps avoid unnecessary care or saves money have ended in ambiguity.
“It isn't even clear that it saves money if you take in the overall cost of delay and care that gets provided later,” he said.
“Say you denied me my MRI, and so I didn't get the MRI. Insurance companies save money that quarter or year. The next quarter or the next year, because I didn't get the MRI, my lung cancer developed into something that requires vast amounts of money that's not accounted for.”
Two bills before the Legislature would create a working group with insurance providers and doctors to come up with recommendations on best practices for prior authorization that they could voluntarily adopt. Both bills also require insurance companies to report prior authorization data to the State Health Planning and Development Agency.
Agency director Dr. Jack Lewin explained those steps can push the system to become better.
“I'd like to be a facilitator of solving those kinds of problems rather than being some kind of heavy-handed regulator,” he said.
“On the other hand, there are times when you need regulation. And that's when you do it this nice way and then nobody changes, then you've got to go the other way. But I think we'll be able to accomplish a lot just by sharing accurate data with people.”
Lewin hopes that eventually prior authorization will be largely automated – and that it could expand participation in clinical research projects across the country.
“There's a way to do this that can actually save the state money, provide better outcomes and better health care, allow us to really give people access to experimental drugs and new therapies before all the science is completed on them, and really solve this problem,” he said.
HB250 awaits a hearing from the Senate Commerce and Consumer Protection, and Ways and Means committees. SB1449 awaits a hearing in the House Consumer Protection Committee.
