Organizations Ask Congress to Pass Bill Curbing Prior Authorization in Medicare Advantage Plans

National and state patient, physician, and healthcare professional organizations—370 in all—are asking Congress to pass a bipartisan bill aimed at curtailing prior authorization requirements in Medicare Advantage, saying that they needlessly delay or deny access to medically necessary care.
Allison Inserro
September 11, 2019
National and state patient, physician, and healthcare professional organizations—370 in all—are asking Congress to pass a bipartisan bill aimed at curtailing prior authorization (PA) requirements in Medicare Advantage (MA), saying that they needlessly delay or deny access to medically necessary care. The bill, called the Improving Seniors' Timely Access to Care Act of 2019 (HR 3107), was introduced in June.

The bipartisan legislation would require CMS to regulate the use of PAs in MA plans. It would define a process to make real-time decisions for services that are routinely approved. These plans would also be required to offer an electronic PA process and report to CMS on how extensively they use prior authorization, as well as how often they approve or deny medications and services.

HR 3107 is sponsored by Representatives Suzan DelBene, D-Washington; Mike Kelly, R-Pennsylvania; Roger Marshall, R-Kansas; and Ami Bera, D-California.

Although most PAs are eventually approved, the use of the so-called “peer-to-peer” process to obtain a PA seems to be growing; one survery found that nearly 20% of respondents experience this requirement for 26% to 75% or more of their services. An American Medical Association survey released earlier this year found similar concerns with the use of PAs. Over a quarter of doctors surveyed said that a PA has led to a “serious adverse event” for patients, such as hospitalization and permanent bodily damage, and 91% of doctors say that PAs are linked with treatment delays.

Another report on a survey of health plan benefit sponsors found that many sponsors are using PA to encourage the use of biosimilars in employer-based plans.

The American College of Rheumatology (ACR), in a statement, acknowledged that PAs are aimed at cost containment, but said their use has spiraled out of control. “Many healthcare plans now use prior authorization indiscriminately, ensnaring the treatment delivery process in webs of red tape and creating gratuitous hurdles for patients and providers,” said Paula Marchetta, MD, MBA, president of the ACR.

Alongside the growing use of PAs, MA enrollment is growing as well. The letter cited a Kaiser Family Foundation report showing that MA enrollment has grown from 18% of beneficiaries in 1999 to 34% this year. In addition, 4 out of 5 enrollees (79%) are in plans that require PA for some services, such as Part B drugs. Starting this year, CMS implemented a change allowing MA plans to use step therapy for Part B drugs. Medicare fee-for-service does not generally require PA for services and does not require step therapy for Part B drugs.

The Congressional Budget Office projects that MA enrollment will rise to nearly half of all Medicare beneficiaries (about 47%) by 2029.

The ACR is part of the Regulatory Relief Coalition, which previously released a national survey of 1602 physicians detailing the effect of PAs on patients and physicians. According to the survey, 87% of physicians report that PA has a significant (40%) or somewhat (47%) negative impact on patients’ clinical outcomes. Nearly one-third of physicians surveyed said their patients often abandon treatment due to PA.

Most physicians (74%) said it takes between 2 to 14 days to obtain a PA, but for 15%, this process can take from 15 to more than 31 days. In addition, 84% of survey respondents said that the regulatory burdens associated with PA have significantly increased over the past 5 years, with half of all practices reporting 11 or more requests per week.

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