Relates to not requiring prior authorization for certain cancer treatments

◆ The sponsor's argument

Why Pete Harckham says this is needed

In recent years, the volume of prior authorization required to ensure coverage of clinical care for oncology patients has significantly increased. Non-profit cancer center Memorial Sloan Kettering (MSK) has reported that they process more than 400,000 prior authorizations per year, requiring them to employ more than 80 Full-Time Equivalent (FTE) workers, and spend more than $10 million each year on related compen- sation, benefits, and vendor costs. The bulk of the work for these FTEs is devoted to processing prior authorizations for guideline concordant cancer treatments which are ultimately approved, but only after the initiation of treatment has been delayed by the prior authorization process and administrative and clinician resources have been expended to obtain it. As a result, pending prior authorization requests and inap- propriate denials, which must be appealed, are the leading cause of delays in the initiation of care for oncology patients. Additionally, a recent study by the Journal of the American Medical Association (JAMA) affirmed that a large amount of insurance denials for oncology care are ultimately approved - after a long delay. Co-author of the study Fumiko Chino, a doctor and assistant professor in radiation oncology, noted that oncology care providers "face barriers pretty much every step of the way for every patient." The JAMA study specifically noted that of 206 denials in radiation oncology, two-thirds of the denials were ultimately approved on appeal without changes. Other studies found even higher rates of approval upon appeal, with as many as 86% of prior authorization requests ultimately being approved after an initial denial. While stuck in the appeal process, several cancer patients face delays in critical and time-sensitive care. Dr. Chino also noted that some cancers, such as cervical cancer, can grow so quickly that each day treatment is delayed, the cancer gets harder to control. She further commented, " it gives you the idea that this entire process might be a little futile - that it's just wasting people's time the problem is cancer doesn't wait for bureaucracy." This bill would prohibit the requirement of prior authorization for treatment that is consistent with NCCN guidelines with Categories of Evidence and Consensus of 1 or 2A as evidence-based standards of care. This legislation, would eliminate unnecessary delays in the delivery of cancer treatment and unnecessary expenses, as insurers have no reason- able basis to deny treatment that is consistent with such guidelinds. Importantly, this bill would maintain the use of prior authorization for treatment where the standard of care is evolving, while also allowing for insurers to conduct retrospective review for medical necessity. It is vitally important that oncology patients have timely access to cancer treatment. This legislation will remove arbitrary administrative burdens which currently serve as roadblocks to lifesaving care.

This is the sponsor's own case for the bill, quoted from their memorandum. It is not Agora's description of what the bill does.