For weeks, health care providers have been telling lawmakers horror stories about dealing with insurance companies.
At a press event last week, Kristen Connolly, a pediatrician at Timber Lane Pediatrics in Milton, told a story about treating a malnourished infant who needed a special formula. But the baby’s health insurer declined to approve that special formula, reversing course only after Connolly spent hours on the phone, writing letters and filling out paperwork.
Then there was Michael, a child who needed a medication for asthma that was not approved by his family’s insurer. Anne Morris, a physician at a University of Vermont Medical Center clinic, told lawmakers in the House Health Care committee in January that it took two months of phone calls and pharmacy visits from Michael’s mother and multiple letters from his doctor to get the medication approved.
And on an everyday basis, the overwhelming burden of time, effort and paperwork needed to make sure insurers will cover procedures and medication for patients is driving people out of an already short-staffed industry, providers say.
Now, lawmakers are considering a bill, H.766, that they hope will streamline providers’ interactions with insurers and give clinicians more bandwidth to see patients — a critical goal amid a chronic shortage of primary care providers and months-long wait times for specialists.
“This bill says, we trust clinicians to provide clinical care,” Rep. Alyssa Black, D-Essex, a primary sponsor of the bill, said in an interview. “Payers pay. Clinicians treat. That’s all.”
But insurance companies say the legislation could raise premiums for Vermonters across the state — at a time when health care costs are already skyrocketing.
“Please be deliberate and fully informed about the impacts of the changes that folks are asking you to consider making,” Andrew Garland, a BlueCross BlueShield vice president, urged a Senate committee earlier this month. “When it comes to the cost of health care, there’s no room for error.”
Streamlining the process
When processing orders and claims, insurers employ a variety of complex and bureaucratic procedures — to the dismay of health care providers.
H.766, which some lawmakers are describing as a “provider burden” bill, aims to remove some of that complexity. Lawmakers are seeking to impose time limits on how quickly insurers must approve or deny requests for drugs, tests or operations, a process known as prior authorization. The bill would implement time limits of 24 hours for responses to urgent requests and two business days for responses to non-urgent ones.
The bill would also direct commercial insurers like BlueCross BlueShield and MVP to align their requirements for prior authorization with those used by Medicaid, which are much less cumbersome. It would also limit the use of step therapy, a practice in which insurers require some patients to try cheaper drugs before trying other, more costly ones.
And H.766 would impose stricter requirements on a process called claim editing. Sometimes, when providers send insurers a claim — essentially, a bill — insurance companies make changes to the procedures that were billed for, and then instead pay (usually less) for those newly edited services.
Providers say that can mean delays in receiving payment, uncertainty about how much money they will get, and more and more layers of bureaucracy to navigate.
The bill has drawn a flood of endorsements from practitioners, hospitals and health care organizations. Providers have said that insurers’ tactics have cost them money, increased workloads, and endangered patients.
“The effects on patients and risks to patient health are tremendous,” Connolly, the Milton pediatrician, said last week.
“The added burnout to an already-thin primary care workforce is significant,” Connolly said. “The challenges with staffing that every primary care office in Vermont is facing (are) made harder when dealing with prior authorizations becomes someone’s full time job — instead of providing direct patient care.”
‘Reining in health care costs’
But insurers say that their procedures eliminate mistakes, cut down on unnecessary spending, and, in rare cases, detect and avoid fraud.
BlueCross BlueShield, which covers roughly a third of Vermonters, estimated that the bill would increase insurance premiums by 5% to 7% next year. And MVP, which covers 37,500 Vermonters, estimated that the bill would increase premium costs for its plans by 3%.
The bill would “saddle Vermonters with much higher out-of-pocket bills at a time when household and employer finances are strained,” Jordan Estey, a spokesperson for MVP, said in an emailed statement. “Vermonters’ health care costs are already too high and unsustainable. H.766 would make matters worse without improving care quality, access, or health outcomes.”
Sara Teachout, a spokesperson for Blue Cross and Blue Shield of Vermont, echoed those concerns.
“All of these things in this bill are some of our strategies and tactics for reining in health care costs,” Teachout said in an interview.
She acknowledged that, due to the complexity of medical billing and H.766’s reforms, the ultimate impact of the bill is unclear — both to the industry and to lawmakers.
“I’ll be the first to admit we do not fully understand the implications of this,” she said. “But clearly the legislature does not.”
‘Both sides have a point’
Lawmakers, meanwhile, have expressed skepticism about insurers’ warnings about higher health care prices.
“Obviously we are very concerned about the cost of health care and cost of premiums to Vermonters,” Rep. Lori Houghton, D-Essex Junction, a sponsor of the bill and the chair of the House Health Care committee, said at the press event organized last week in support of the bill. “We all have to pay for insurance as well.”
But Houghton and other bill sponsors have argued that freeing up practitioners to see more patients and reducing burnout would drive down prices in the long run. That would also help keep patients out of emergency departments, where costs are exorbitant, proponents say.
The bill seems to have broad support among lawmakers, at least in the House. The legislation unanimously passed the chamber last month, with a dozen lawmakers absent. Currently, the legislation is in the Senate Health and Welfare committee, where chair Sen. Ginny Lyons, D-Chittenden Southeast, said it will likely be voted out in the next two weeks.
Not everyone is convinced, however. Several employers have urged lawmakers not to pass the bill, saying that the higher premiums predicted by private insurers would strain their budgets.
Last month, at a committee meeting attended by representatives of various health care entities, Mike Fisher, Vermont’s chief health care advocate, hedged on whether the bill would do more to harm or help.
“I and my office often sit between payers and providers as they point fingers at each other for being the reason why our health care system is so expensive. And I often end up thinking, well, both sides have a point here,” Fisher said.
“If I do my testimony right today,” he noted, “everyone sitting behind me will be mad at me.”