Prior Authorization Front and Center
HHS OIG Report Gives Credence to Years of Provider Complaints
For almost a decade, the Alliance of Specialty Medicine has advocated for a closer look at health insurers’ abuse of the Prior Authorization process by private health insurers. In fact, in a 2016 survey of over 1,000 specialty providers, close to 90% responded in the affirmative when asked if they had to delay treatment for a patient due to the prior authorization process. More recently, Dr. John Ratliff, a practicing neurosurgeon at Stanford University, wrote a detailed account of his experience with prior authorization delaying necessary surgeries for his patients.
Prior authorization is a cumbersome process that requires patients to obtain insurance company approval for the medical treatments or tests prescribed by their treating physicians. The process for obtaining this approval is lengthy and typically requires physicians or their staff to spend several hours and sometimes days negotiating with administrative staff at insurance companies on the best course of timely care for a given patient. While this process can play a role in ensuring medical services and medications are medically necessary, prior authorization in its current form has become nothing more than a bureaucratic tool for the insurance companies to protect their bottom line, often at the expense of positive patient outcomes.
Bipartisan legislative remedies have been introduced in both the U.S. House and Senate to reform the prior authorization process, most notably in the Medicare Advantage (MA) program. This bill, the Improving Seniors’ Timely Access to Care Act (H.R. 3173, S.3018), would improve the prior authorization process in MA plans by increasing transparency, requiring adherence to evidence-based medical guidelines, establishing an electronic process, and minimizing the use of prior authorization for routinely approved items and services. Unfortunately, despite being bipartisan and widely supported in both chambers of the Capitol, this prior authorization reform bill had not gotten much attention or movement from Congressional or committee leadership.
That all changed in April with a startling report from the Department of Health and
Human Services (HHS) Office of the Inspector General (OIG). The report found that MA plans continually delayed or denied care or services to Medicare beneficiaries, often due to using clinical criteria not contained in Medicare coverage rules or incorrectly claiming that patient documentation was incomplete. Moreover, the HHS OIG validated years of anecdotal evidence by patients and providers that the unnecessary hurdles put in place by MA plans “may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.”
Responding to this report and the ensuing media coverage, the House Energy and Commerce Committee’s Oversight Subcommittee convened a hearing entitled, “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans.” This hearing highlighted needed reforms for the M.A. program, including insurers’ use of the prior authorization process, and several subcommittee members offered their support for H.R. 3173. The House version of the bill currently has over 300 cosponsors, while over 35 Senators support the legislation on the other side of the Capitol. Within weeks of the hearing, the House Ways and Means Committee passed a version of the Improving Seniors’ Timely Access to Care Act (H.R. 8487) by voice vote. The bill now awaits action by the House Energy and Commerce Committee before going before the full House of Representatives.
It’s rare to see this much bipartisan enthusiasm for any legislation. With this renewed focus on removing barriers to patient care, the Alliance of Specialty Medicine will continue to press for final passage of the Improving Seniors’ Timely Access to Care Act before Congress adjourns at the end of the year.
Medicare Payment Rollercoaster Continues
Inflation, Sequester, Physician Fee Schedule Contribute to Provider Worries
The proposed rule for the 2023 Medicare Physician Fee Schedule (MPFS) was released by the Centers for Medicare & Medicaid Services (CMS) in early July. As with previous fee schedules, the 2023 MPFS proposes to cut physician reimbursement by nearly 4.5% due to statutory requirements that any overall changes to the MPFS remain budget neutral and the expiration of the last year’s one-time 3% positive payment adjustment included in Protecting Medicare and American Farmers from Sequester Cuts Act (S. 610) for CY 2022.
The summer release of the MPFS proposed rule begins the mid-year focus by policymakers and stakeholders on how to handle the imminent cuts that Medicare providers will face in the coming year. CMS determines the increases and decreases in physician payment levels based on several factors, including physician-focused value-based care initiatives authorized under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. However, many specialty medical societies, including members of the Alliance of Specialty Medicine, remain very frustrated with the manner in which MACRA is being implemented to the exclusion of specialty care.
In addition to the unbalanced treatment specialists received under MACRA, the provider community is bracing for another hit due to the 4% Statutory Pay-As-You-Go Act of 2010 (P.L. 111-139), which was postponed for one year and will take effect on January 1, 2023, unless Congress acts. This combined 8.5% payment cut is on top of the annual 2% Medicare sequester cuts — mandated by the Budget Control Act of 2011 (P.L. 112-25) — which resumed in full force on July 1.
While absorbing these cuts over the years while simultaneously coping with added 
expenses due to the COVID-19 pandemic, providers also encountered a broader economic issue in 2022: inflation. Physician practices are not immune from the supply chain and labor shortage issues plaguing the country, and these market issues affect their bottom line like any small business. However, unlike companies that raise their prices to remain in business, the MPFS does not provide physicians with an inflation adjustment. Since most private insurers’ rates reference Medicare prices, the artificially low rates in that program are reflected across the board. Dr. Michael Lai, a retina specialist practicing in the Washington, DC area, recently shared how inflation has impacted his practice in an Op-ed.
Physicians across the nation will be working with their specialty medical societies to submit comments to CMS on the proposed MPFS rule while also asking Congress to take action to stabilize the Medicare payment system in light of the continued burden of the COVID-19 pandemic as well as record-setting inflation.
Specialty Docs Head to the Hill (Virtually)
Advocacy Fly-In Highlights Access and Payment Issues
Over 100 specialty physicians from across the nation logged in to their computers in early June to discuss health policy issues with leading lawmakers from the House and Senate. The Alliance of Specialty Medicine’s bi-annual Legislative Advocacy Fly-In featured a dozen bi-partisan Members of the U.S. House and Senate, many of whom were practicing physicians before coming to Congress.
During the advocacy fly-in, Alliance physicians discussed their federal agenda, which included federal legislation to remove barriers to care such as prior authorization and step therapy, as well as the growing need to address the physician workforce shortage, which is growing as a result of the accelerated departure of men and women from the medical field due to an aging physician workforce, burnout and COVID-19-related challenges. Medicare reimbursement was also a topic of discussion as specialty physicians absorbed a 2% reimbursement cut due to the resumption of the Medicare sequester and the calendar 2022 changes to the Medicare Physician Fee Schedule (MPFS). The proposed rule for the 2023 MPFS was recently released by the Centers for Medicare & Medicaid Services (CMS), meaning more looming cuts to physicians serving Medicare patients.
The Alliance also used its active presence on social media to highlight the advocacy
fly-in. The @specialtydocs Twitter handle posted reactions and comments throughout the day using the hashtag #ASMFLYIN. Medical societies and individual specialty providers also chimed in from around the country, resulting in over one million Twitter impressions.
Advocacy for access to specialty care is a key pillar of the Alliance’s mission. The group plans to return to Capitol Hill in the fall, either virtually or in person, depending on current COVID-19 protocols.
Getting a Seat at the Table
Physician Presence in Congress is Key to Effective Health Policy
The American Society for Dermatologic Surgery (ASDSA) recently initiated a program to educate and support its members who want to run for public office or join their state medical board. Over 50 members have attended the Legislative and Medical Board Academies webinars and training sessions. George Hruza, MD, ASDSA, Past President and former liaison to the Alliance of Specialty Medicine, is running for Missouri State Senate. He also is a member of the American College of Mohs Surgery (ACMS). Information about Dr. Hruza’s campaign and specialist-friendly platform can be found here: https://hruzaformissouri.com/
Throughout its history, the U.S. Congress has counted physicians in its ranks in the
House and Senate. The first practicing physician elected to Congress was Henry Latimer of Delaware, a surgeon in the Revolutionary War. He came to Congress as a Federalist in 1795 and served for six years. In the years that followed, physician presence in Congress was never more than a few Members. By 1990, there were only two.
That all changed with the passage of the Affordable Care in 2009. Realizing that healthcare policy was now front and center in American politics, doctors began to run for office in much greater numbers, culminating in a record number of 21 physicians serving in Congress by 2013. Currently, there are 17 physicians serving in Congress, with 13 in the U.S. House and four in the U.S. Senate.
This trend is unlikely to change. Issues related to the COVID-19 pandemic, such as masking, vaccines, and treatment, will keep physicians focused on elected politics at the local, state, and federal levels. Specialty physicians like Dr. Hruza and fellow ASDSA member Rep. John Joyce (R-PA) will stay in the fight for common sense healthcare policy.
AGA advocacy drives Medicare to eliminate colorectal cancer screening cost-sharing
In a huge win for patients, the Centers for Medicare and Medicaid Services (CMS) will begin covering colonoscopies after a positive non-invasive stool test for colorectal cancer screenings starting next year. Medicare was previously the only insurer that did not cover this critical prevention procedure.
This change comes after a year of advocacy led by the American Gastroenterological Association (AGA), including multiple meetings with senior officials in the Administration and legislative pressure by AGA members across the country.
In September 2021, former AGA presidents John Inadomi, MD, AGAF, and David Lieberman, MD, AGAF, met with Assistant Secretary of Labor Ali Khawar and representatives from the U.S. Department of Health and Human Services and U.S. Department of Treasury to request they direct private health plans to cover colonoscopy after a positive non-invasive colorectal cancer (CRC) screening test.
In response to the meeting, the Administration issued guidance for private insurers to cover colonoscopies following a positive stool-based test. Still, AGA continued to advocate for Medicare beneficiaries to receive the same coverage.
In June 2022, AGA president John Carethers, MD, AGAF, and former president Dr.
Lieberman continued AGA’s advocacy efforts and met with CMS to emphasize the need for Medicare to cover the full CRC screening continuum.
Shortly after this meeting, as part of its comprehensive Medicare Physician Fee Schedule, CMS announced a proposed change to Medicare benefits, covering the necessary colonoscopy after a positive non-invasive screening test without cost-sharing beginning Jan. 1, 2023. AGA continues to urge CMS to finalize the proposal.
“Cost-sharing is a well-recognized barrier to screening and has resulted in disparities. Patients can now engage in a CRC screening program and be confident they will not face unexpected cost-sharing for colonoscopy after a positive non-invasive screening test,” says David Lieberman, MD, AGAF. He met with CMS officials multiple times to push this policy forward. “AGA knows that increased participation in screening will further reduce the burden of colorectal cancer.”