Jane Pringle: Reducing Barriers to Health Care for Mainers

By State Rep. Jane Pringle

The new year is a wonderful time to give thanks for the health and wellness of family and friends. All across the state we have many great medical providers striving to provide essential care for those who need it. 

State Rep. Jane Pringle

In a perfect world, receiving medical care would be as easy as going to the provider’s office, being assessed, being prescribed a course of care, and then receiving that treatment. Unfortunately, our health care system does not function that way. The current system requiring prior authorizations has created significant barriers for medical professionals striving to deliver effective patient care.

This session, I’ve introduced a bill that would improve the administrative process of prior authorization for medical professionals. Prior authorization is a system set up by insurance companies-public and private-to provide a health-plan cost control process. If a patient's treatment or test is deemed too costly, the insurance company will review whether it is medically necessary for the patient or if a less expensive test or treatment should be tried first. They will then decide whether to approve the course of treatment or reject it. Some of these systems are based on medical evidence and some of these systems are arbitrary and aimed at reducing expenditures, regardless of whether or not it will cause harm to the patient.

In recent years, prior authorization requests have increased. This has proven to be an obstacle to care and, I believe, is leading to the increased cost of healthcare. The lack of standardization of systems across many insurance companies creates a mountain of administrative work for the medical professionals trying to get their patients the care they need.

A case that demonstrates the system's pitfalls is that of a young mother who developed a pulmonary embolism (blood clot to the lungs) after giving birth. She required blood thinners for several months. Her family physician and her hematologist prescribed a well-known, cost-effective blood thinner that was deemed safe for her to use while nursing her newborn. This life-saving medication was essential in preventing the young mother from having another clot. Her prescribed course of care required 65 days of treatment, but her insurance company only authorized 15 days' worth of medicine. In reaction to the insurance company’s denial of care, the patient’s doctor’s office was forced to scramble and work tirelessly to appeal the decision.

With five days to spare, they were able to get the patient the amount of medicine she needed at an affordable price. Despite this resolution, the delay of prior authorization required a significant amount of time and resources from the staff. It was time that could have been better spent on patient care rather than dealing with the clerical obstacles presented by insurance companies.

With this patient example and so many others in mind, I look forward to continuing to work on my bill to improve the prior authorization process. Over the past several months, I have worked with many stakeholders – employers, insurers, hospitals, physicians, nurse practitioners, physical and occupational therapists, and healthcare advocacy organizations – to strengthen the rules and create a public “report card” about insurance carrier’s behavior. This report will reveal how many initial approvals, denials, and appeals insurance companies are issuing, and will illuminate whether they are delivering benefits to customers as promised. Holding these organizations accountable will ease the administrative burdens on healthcare providers and, ultimately, reduce the cost to patients.

I look forward to collaborating with my colleagues to get this legislation enacted into law. <

State Rep. Jane Pringle is serving her second non-consecutive term in the Maine House of Representatives, having previously served from 2012 to 2014. She is currently a member of the Legislature’s Health Coverage, Insurance and Financial Services Committee in the 131st Maine Legislature.