Some New Jersey patients can’t access medicine due to insurance hurdles. A new law is trying to speed up the prior authorization process

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New Jersey resident Sandra Johnson started feeling short of breath a few years ago, and sometimes it really limited what she could do.

“Getting up to walk from my bedroom to the bathroom, I will be so out of breath that I would have to just sit on the toilet with the seat down … to prepare myself to get up to take a shower,” she said.

Her physician diagnosed her with severe persistent asthma and prescribed an injectable drug. Before she could get started on the treatment, Johnson’s doctor had to go back and forth with her insurance provider to convince them that she really needed this drug, a process called prior authorization. The insurance company approved it, and once Johnson got the treatment, she said she felt better. She could go back to her job as a clinical coordinator, do chores and go grocery shopping without trouble.

But a few months ago, her insurance provider needed prior authorization again, for the same treatment. This time, the answer was no. Johnson has been without the medicine for months.

“I don’t have an understanding of why it’s being denied when this medication that I have been taking has been working for me, allowing me to have a better quality of life and being able to function on an everyday basis.”

This is a common and disruptive problem, said Tina Shah, a pulmonary and critical care doctor in New Jersey and also the chief clinical officer of Abridge, a medical AI company.

“This causes so much moral distress that I often go home, and I have to decompress because I know that I can be the best doctor, but because of prior authorizations I often can’t deliver the best care,” she said.

More than 90% of doctors said their patients have had to delay their health care because of prior authorization, according to a 2022 survey by the American Medical Association. A third of the doctors in that survey said the delay led to serious problems for their patients, like a life-threatening event, or hospitalization.

Shah recalled one of her patients, who had a history of endometrial cancer and had been trying to find out the status of the cancer for months. The insurance company denied prior authorization for medical imaging. This patient ended up in intensive care with a life threatening blood clot, and got the medical imaging, which also showed that the cancer had spread.

“She finally got the answer she desperately wanted for the last few months,” Shah said. “But she’s now grappling with much more advanced cancer and needing to be on lifelong blood thinners.”

A new law that was passed in New Jersey this January aims to address those issues and speed up the process. Once it takes effect next year, health insurance companies have to decide on prior authorization within three days. If a doctor says their patient needs medicine urgently, the insurance company has to approve or deny within 24 hours.

Catherine Trillo has been a registered nurse in New Jersey for more than 30 years, and said she sometimes spends hours each day dealing with this issue on behalf of patients. She said the reform bill will make a big change for patients and medical staff.

“If this is the last thing I do in my career, It’s awesome … it makes a permanent step towards improving health care.”

Shah echoed that sentiment.

“I actually have hope that I’m not just a widget in the health care industry,” she said. “When this bill goes into effect in January 2025, we’re going to feel it,” she said. “It’s going to … allow me to do what I actually trained to do — spend time with my patients and try and make them feel better.”

Ward Sanders represents the health insurance companies in this debate, as the president of the New Jersey Association of Health Plans.

He said it’s good that the law requires faster decisions, but added that prior authorization is not just red tape — the process is in place for a reason.

“The goal of prior authorization is to provide the right care at the right time and the right setting and to allow for the efficient allocation of resources.”

He said, for example, insurance companies will sometimes ask doctors to consider cheaper drugs that achieve the same therapeutic effect. He pointed to a line in New Jersey’s state budget documents last year saying that prior authorization saved the state health insurance program for public employees almost $100 million.

This debate will continue. New Jersey was the second state to pass this kind of legislation after  Washington state, but there are more than 20 states with similar bills going through the legislative process.