House Bill seeks to cut paperwork on pre-authorizations in Medicare
WASHINGTON – Medicare Advantage insurers need to be clearer about their pre-authorization policies, according to a panel of House members.
“When I was practicing, I regularly faced burdens and processes like this,” Rep. Larry Bucshon, MD (R-Ind.), Who previously worked as a thoracic surgeon, said at a press conference. Thursday announcing the introduction of HR 3173, the Improved Access to Timely Care for Seniors Act.
“It has chained doctors, nurses and other healthcare workers to their desks instead of spending time caring for patients,” he said. “We certainly need increased transparency in this pre-authorization process. We need to eliminate bureaucracy; we need to modernize the system, make it more user-friendly, so that we can make decisions faster and in a timely manner, in particular for routine care. “
“Prior Authorization” refers to the requirements of health insurers that providers must obtain advance authorization for a particular treatment so that the insurer can reimburse it. Prior authorization has long been the bane of many suppliers’ existence, with its accompanying documents, faxes and phone calls.
Accountability for approval, rejection rate
The bill Bucshon was discussing would establish an electronic pre-authorization process and require the Department of Health and Human Services to create a real-time decision process for regularly approved items and services, explained Suzan DelBene (D- Wash.), One of the main sponsors of the bill. This would require Medicare Advantage plans to report on their use of prior authorization and their approval and denial rates, and would encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines. , she said.
“We saw overwhelming support for this measure at the previous Congress,” said DelBene. “We have over 280 co-sponsors … 218 is the magic number in the House, so it shows that we have strong bipartisan support for this bill.”
The bill also received the support of more than 70 leading healthcare providers and patient advocacy organizations around its introduction, she added.
Rep Mike Kelly (R-Pa.), Who previously worked in the auto industry, compared health insurers to the auto industry. “A lot of those things are basically about being able to provide the care you need in a timely manner so that you don’t get left in limbo,” he said.
If something goes wrong with an auto warranty, “I can phone and call someone at General Motors, or call someone at Hyundai, Kia, or Toyota, and I can get a direct response and they’ll give me permission to go.” . to come in and do something more than what was prescribed, ”Kelly said.
“If you want a customer to come back to you, give them a good service. If you want to lose them forever – don’t, and they’ll never come back. We have to have some kind of standards set. to have some sort of clarity, ”Kelly added.
“Do not add to clinical care”
Rep. Ami Bera, MD (D-Calif.) Agreed with this analogy: “I think healthcare is a service industry – we’re here to serve our patients,” he said. “When I first practiced you had prior clearances, but they were really there for rare and unexpected interventions, and it was totally appropriate … Fast forward to today or to ‘40% of the doctor’s time is spent on administrative activities that are not clinically related. “
“If you talk to a lot of doctors who practice today, they have to hire an additional one to three employees just to fill out the paperwork, and that doesn’t add to clinical care,” Bera said. “We didn’t go to medical school to learn how to fill out paperwork; we went to medical school to learn how to take care of our patients.”
The bill “is an important first step in bringing this practice into the 21st century, to ensure that we put the patient at the center of health care delivery,” he said.
George Williams, MD, who spoke on behalf of the American Academy of Ophthalmology, gave an example of how prior authorization can interfere with care: “Just yesterday I assessed a 67-year-old man with sudden loss of vision and examination. He had advanced diabetic retinopathy with eye bleeding and swelling of the retina. He was no longer able to read or drive and was therefore unable to work. “
The patient “needed immediate treatment with the injection of FDA-approved drugs into his eyes,” said Williams, an ophthalmologist in Royal Oak, Michigan. “This is the standard of care. Unfortunately, he had a Medicare Advantage plan that requires prior authorization for any treatment, and if approved, the treatment required would be with a drug not approved by the FDA for that indication.”
“In my experience, such an approval usually takes a few to several days … and since it needed immediate treatment, I proceeded to treatment with a sample of the FDA-approved drug that I believed. be the best treatment. It is unlikely that any of these services will be covered by his insurance, ”said Williams.
“Even when treatment is not urgent, the vagaries of prior authorization require my practice to devote a great deal of time and resources to obtaining approval,” Williams continued. “Such approval is granted more than 90% of the time, indicating that the prior approval process rarely reduces costs, but generally delays access to care.” This delay in access is forcing patients to return for additional and otherwise unnecessary office visits which add to the burden of treating our patients. . It is an inefficient way of delivering health care. “
Move through the process
The bill was tabled on May 13 and must now go to a committee of the House. DelBene and Kelly are both members of the House Ways and Means Committee, “and we’re working to get it through there,” DelBene said, adding that there will also be a companion bill in the Senate. . Kelly said the group sponsoring the bill also had “very good allies in the Senate.”
Asked why the bill only applies to Medicare Advantage plans and not commercial insurers, Bera said, “When we first started thinking about it, obviously we were thinking about it in general, but we wanted to create a grand coalition and Medicare Advantage seemed like the right place to start. And I would say this as a starting point, not an end point “in terms of possibly including other types of plans.
DelBene said, “It also helps to set a precedent. When we show how well it can work, it will also put more pressure on others to adopt a similar model in the future.”
As for the insurance industry’s response to the measure, “we have worked with insurers throughout this process,” said DelBene. Bera noted that the group “went out of their way to work with the health plans; we don’t want to take an adversarial approach. We took their advice and tried to incorporate it where appropriate.”
In response to an email from MedPage today, a spokesperson for America’s Health Insurance Plans, the health insurance industry’s trade group, said the group is currently reviewing the bill.