ALLIANCE OF SPECIALTY MEDICINE PARTICIPATES IN CMS ROUNDTABLE ON PRIOR AUTHORIZATION REFORM
Physician Specialists Document Abuses And Applaud Biden Administration’s Efforts To Fix The System
In January, The Alliance of Specialty Medicine (Alliance) participated in an in-person roundtable discussion on reforming prior authorization in federally-sponsored healthcare programs. The panel was convened by Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, and U.S. Surgeon General Vice Admiral Vivek H. Murthy, MD, as the Biden Administration looks to remedy documented abuses in the prior authorization program and ensure patients’ timely access to medically necessary care.
The Alliance specialty physicians who participated in today’s roundtable echoed these findings.
Eugene Y. Rhee, MD, MBA, public policy chair of the American Urological Association, said, “Prior authorization is a barrier to care that profoundly harms patients. The AUA applauds CMS for the opportunity to participate in today’s dialogue about how we can remove this barrier so that patients can get the care they need when they need it. Ongoing communication is key to ensuring CMS understands and addresses the daily challenges that physicians and their patients face.”
Shivan Mehta, MD, MBA, a gastroenterologist who attended the meeting for the Alliance, noted, “We know that health disparities exist in many GI conditions and diseases, and prior authorization only exacerbates this problem. The solutions that HHS is offering will make a difference in ensuring patients can get the care they need when they need it.”
Also attending for the Alliance was Katie O. Orrico, Esq., SVP for health policy and advocacy for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, who added, “It’s long past the time for CMS to hold health plans accountable for unconscionable delays and denials of care. The Alliance looks forward to CMS finalizing these proposals, which will eliminate care delays, patient harms, and practice hassles contributing to physician burnout.”
The Alliance has been a long-time proponent of reform to prior authorization. Unfortunately, the program has devolved into a cumbersome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. The process for obtaining approval is lengthy and typically requires physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies — time that would better be spent taking care of patients. Patients experience significant barriers to medically necessary care due to prior authorization requirements for items and services that are eventually routinely approved.
The Alliance recently released a survey of its physician members about prior
authorization and other utilization review practices. Respondents overwhelmingly indicated that the use of prior authorization (PA) has increased in the last five years across all categories of services and treatments:
- Over 93% of respondents answered that PA has increased for procedures;
- More than 83% responded that PA has increased for diagnostic tools, such as labs and even basic imaging;
- Ninety-two percent reported that PA has had a negative impact on patients; and
- Two-thirds (66%) answered that PA has increased for prescription drugs, with physicians noting that even many generic medications now require pre-approvals.
The Biden Administration recently proposed several regulations to improve prior authorization:
- Advancing Interoperability and Improving Prior Authorization Processes
- Strengthen Beneficiary Protections, Improve Access to Behavioral Health Care, and Promote Equity for Millions of Americans with Medicare Advantage and Medicare Part D
- Standardize Electronic Health Care Attachments Transactions and Electronic Signature Processes to Improve the Care Experience for Patients and Providers
The Alliance is currently reviewing these proposals and will submit written comments. In addition, the Alliance is also advocating for statutory reforms, including the bipartisan Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018), which closely aligns with the provisions included in the CMS prior authorization proposals. The House bill had 327 cosponsors and passed unanimously by voice vote. The Senate bill had 53 bipartisan cosponsors, but unfortunately, the bill was not included in the Consolidated Appropriations Act of 2023 at the end of last year.