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Kaye Pestaina, Vice President and Co-Director, Program on Patient and Consumer Protections with Kaiser Family Foundation.
Kaye Pestaina provided a broad overview of the state of claims denial, which stands at an average of 17% but varies significantly across states. For instance, Delaware experiences high denial rates, whereas Maryland, Pennsylvania, and New Jersey see lower figures. Surprisingly, only 0.2% of these denials go to appeals, with 60% of these appeals being upheld. A notable point was that six in ten individuals face insurance issues, with 16% encountering prior authorization challenges, especially those with chronic illnesses. A concerning finding is that about half of the patients are unaware of their right to appeal. Refer to accompanying slides: Claim Denials, Claims Data, and Insured Problems with Insurance.
Anna Hyde, Vice President of Advocacy and Access, Arthritis Foundation.
Anna Hyde focused on the complexities of Step Therapy. She revealed that 70% of patients are required to undergo this process, with 39% having to try three or more drugs and 30% two drugs. The primary reason (49%) for this is failure of previous medications. The waiting time for approvals is also alarming, with 50% waiting over five days and 42% over seven days. Hyde highlighted the emotional (70%) and physical (50%) co-morbidities resulting from these delays. Her discussion on prior authorization issues was supplemented with informative slides. Refer to accompanying slide: Step Therapy.
Michael Humphreys, Commissioner, Pennsylvania Insurance Department.
Michael Humphreys discussed the recent Consensus Legislation in Pennsylvania, which includes provisions for electronic submissions, staff training, and an external review process involving the State Insurance Department. His presentation, detailed through additional slides, offered a blueprint for effective legislative action and is important for us to follow as legislation being introduced in Delaware is modeled after Pennsylvania. Refer to accompanying slides: Prior Authorization Findings and Appeals & Denials Review.
Key Points from the Q&A Session:
The Q&A session was particularly illuminative. Topics ranged from issues with repeat Step Therapy upon changing insurance providers, the need for physician involvement in complaints and appeals with the State Insurance Department, to the necessity for data transparency and ending data siloing. A detailed discussion focused on navigating complexities with commercial insurance, Medicare Advantage, Medicare, and ERISA. A critical issue raised was the slow response to federal complaints, often taking up to six months.
As a physician community, we must continue to advocate for transparency, efficiency, and patient-centered approaches in insurance processes. The insights from this session will be invaluable in guiding our efforts and conversations with policymakers, insurance companies, and health care professionals.
Thank you for your continued commitment to MSD. Together, we can strive towards a health care system that is more accessible and equitable for all.
Look for my next communication highlighting another topic from this Summit, "Conversations with Leading State Regulators."
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