Initially intended by insurance companies and pharmacy benefit managers as a utilization management tool to reduce the inappropriate use of medications and procedures, prior authorization (PA) has morphed over the last two decades into a cost-containment strategy that too often delays or denies necessary care.

Every morning, when I walk into my clinic, I know that dozens of prior authorization requests will be waiting for me. While some may be for off-label indications of complex medications, most PA messages in my inbox are unnecessary, duplicative, or outright barriers that delay care. It is not uncommon to receive a PA for a patient with rheumatoid arthritis who has been stable on a biologic medication for over two years. Nearly every such PA is eventually approved after a tedious back-and-forth involving my clinic staff and hospital pharmacists, who help complete the paperwork and upload documents to insurer website portals. However, the process often leads to delays, causing patients to miss doses, experience disease flares, and suffer unnecessary complications.

For my patients with particularly brittle inflammatory disease, the consequences of PA-related delays can be ghastly. Patients suffering from uncontrolled inflammation can endure weeks or even months of unnecessary pain and worsening symptoms, taking a toll on their health and personal relationships and risking their ability to work or even survive. Not infrequently, patients lose their jobs or are forced onto FMLA or disability due to treatment delays caused by PA approvals. And tragically, some have even died. Every year, I have the heartbreaking task of calling the loved ones of my patients who have died from their autoimmune disease. These conversations are never easy, often revolving around the horrors of our broken insurance system and the painful question: "Why couldn't they get their medication sooner?"

Ensuring Thoughtful Legislation—And Why Words Matter.
Prior authorization reform is urgently needed in Washington state—we were falling behind other states. Meaningful legislative change has been a priority for physicians and patient advocates alike. KCMS physicians have crafted resolutions calling for greater transparency, accountability, and fairness in the PA process.

During this past legislative session, two proposed bills (SHB 1566 / SSB 5395) prompted important conversations about PA reform. While well-intended, some of the bill language raised concerns about potential unintended consequences—particularly around increasing PA denials and allowing for more retroactive denials of care that had already been approved. Given the complexity of prior authorization policies, ensuring that the wording is precise and does not inadvertently weaken reform efforts is critical.

KCMS physicians and advocates raised these concerns, and after discussions, the bills were deferred in the House and Senate fiscal committees for further consideration. This outcome underscores the importance of thoughtful policymaking that protects patients from unnecessary administrative barriers.

What Comes Next in Prior Authorization Reform? The Power of Physician Advocacy
KCMS physicians remain committed to advocating for stronger protections against harmful PA policies that delay care, create unnecessary administrative burdens, and put patient health at risk. Moving forward, key reform priorities include:

Join the Effort—Your Voice Matters
KCMS remains committed to working alongside physicians, healthcare advocates, Washington state lawmakers, and the Office of the Insurance Commissioner to advance meaningful prior authorization reform.

Has prior authorization delayed or denied care for your patients? We would like to hear from you. Your stories will help us continue to advocate for reform and shape the conversation.

📩 Please send your experiences to info@kcmsociety.org
Thank you. Together, we are making a difference.