Dear Chairman Lampton, Vice Chair Barhorst, Ranking Member Miranda, and Honorable Members of the Committee:
On behalf of the more than 1,600 people with cystic fibrosis in Ohio, we write to provide testimony for HB 130, 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. While we support the bill’s goal of streamlining the prior authorization process, we request that this committee amend HB 130 to ensure appropriate utilization of the physician exemption. Doing so will help ensure immediate and consistent access to critical therapies for Ohioans with CF.
About Cystic Fibrosis and Prior Authorizations
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 serious infections. CF care is grounded in evidence-based clinical guidelines and as a complex, multi-system disease, CF requires an intensive treatment regimen including multiple medications. For people with CF, it is not uncommon to take seven therapies every day, and as many as twenty. Many medications are taken year after year, and in most cases, for life. While these therapies are helping people live longer, healthier lives, we also know 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.
PAs can also cause significant administrative burden for CF providers and are often redundant for medications that people with CF must take indefinitely to maintain their health. In a 2019 CF Foundation survey of over 100 CF care center directors, 60 percent cited the time and resources required for prior authorizations as one of the biggest barriers they face in supporting access to care and treatment. This arduous process diverts valuable time and resources away from direct patient care.
We appreciate Ohio’s attention to this issue and offer comments on the following provisions in HB 130:
Gold Carding
To reduce administrative burden and delays in care, HB 130 exempts providers from PA requirements if 95 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 a 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.
The Cystic Fibrosis Foundation supports gold carding as an important tool to reduce administrative burden for physicians with a proven track record of PA approvals; however, we cannot support HB 130 in its current form. We find the amended approval rate required for a gold card to be unnecessarily prohibitive and ask that it be reduced to 80 percent, as specified in the original bill. The current approval rate of 95 percent is overly restrictive, functionally only allowing for one denial out of every 20 requests submitted. This threshold risks excluding experienced physicians with specialized knowledge of CF from receiving an exemption. 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. In those scenarios, physicians may be denied gold carding when the payer is the one causing an unnecessary barrier to care. We ask that you amend the approval rate for prescribers to 80 percent, as originally specified.
Finally, the Foundation urges the committee to amend HB 130 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.
Transparency for Prior Authorization Requirements
The CF Foundation also supports the provision of HB 130 to increase transparency for PAs, specifically the requirement to make PA data readily available in an accessible format on health insurers’ and Ohio Department of Medicaid's public websites. We encourage Ohio to bolster these transparency efforts by requiring insurers to maintain a complete list of services that require PA and mandate that PA requirements and criteria — and changes to these policies — are easily accessible and clearly articulated. Increasing the availability of information on PA requirements and processes at the point-of-care will help reduce the administrative burden of these policies and streamline the process for care teams.
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. If amended, HB 130 provides an opportunity to make prior authorization processes more transparent and efficient, allowing for timely access to appropriate treatments.