Healio Special Report: Health Care and Politics

Healio Special Report: Health Care and Politics

September 11, 2019
2 min read

370 medical groups petition Congress for prior authorization reform

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Paula Marchetta

The American College of Rheumatology has joined 369 other patient, physician and health care professional groups in calling on Congress to pass a bipartisan bill that would amend the Social Security Act to regulate the use of prior authorization for patients with Medicare Advantage plans.

“While intended to control costs, the unregulated use of prior authorization has devolved into a time-consuming and obstructive process that often stalls or outright revokes patient access to medically necessary therapies,” Paula Marchetta, MD, MBA, president of the ACR, said in a press release. “Many health care plans now use prior authorization indiscriminately, ensnaring the treatment delivery process in webs of red tape and creating gratuitous hurdles for patients and providers. Patients, physician groups, hospital associations and other key stakeholders all agree that reform is needed.”

The bill, H.R. 3107, also known as the “Improving Seniors' Timely Access to Care Act of 2019,” was introduced in the U.S. House of Representatives, and referred to the Ways and Means Committee and Committee on Energy and Commerce on June 5. It is sponsored by Rep. Suzan DelBene, D-Wash., and cosponsored by representatives Mike Kelly, R-Pa., Roger Marshall, R-Kan., and Ami Bera, D-Calif.

According to the letter, the bill would, among other provisions, establish a process so that “real-time decisions” can be made regarding services that are routinely approved. In addition, the legislation would require Medicare Advantage plans to offer an electronic prior authorization process, and to report to CMS the extent of their use of prior authorization, as well as how often they approve or deny medications and services, the letter said.

The letter noted that this reform will provide “much-needed oversight and transparency of health insurance for America’s seniors” considering that 22 million people — approximately 34% of all Medicare beneficiaries — are currently enrolled in Medicare Advantage plans, and 79% of those patients are in plans that require prior authorization for select services.

In a 2018 survey conducted by the AMA, 28% of physicians reported that prior authorization has led to a “serious adverse event” for patients in their care, such as hospitalization and permanent bodily damage. Survey results also demonstrated that 91% of physicians report that prior authorization is associated with treatment delays.

The letter states, “For our seniors — and as representatives of organizations seeking to protect patients from delays in care and relieve unnecessary administrative burdens that impede delivery of timely care — we are committed to advancing this legislation in Congress and ask that you join Representatives DelBene, Kelly, Marshall, and Bera in co-sponsoring H.R. 3107 and securing its enactment.”

The ACR is supporting the legislation as part of the Regulatory Relief Coalition, a group of national physician specialty organizations that advocate against what they describe as regulatory burdens within Medicare, with the stated goal of protecting patients’ access to timely care.– by Robert Stott