Health groups say requests for permission are delaying patient care and putting more pressure on overworked staff. Advocates say a bill to renew the Medicare Advantage plans process would help millions.
Doctors and other health care advocates have criticized the pre-licensing process for years, but some see an opportunity for reform.
Congressional lawmakers are pushing legislation to simplify the pre-authorization process in Medicare Advantage plans, which is used by millions of seniors. In pre-authorization, certain drugs and treatments must be approved by physicians and practices.
While insurance companies claim the advance clearance is designed to reduce unnecessary treatments and wasted spending, doctors say the process is too demanding and often results in patients being denied medication or at least seeing a delay in treatment. They also say it is time-consuming for health care workers who are already overworked and understaffed, adding that it is a major contributor to burnout.
Although some say demands eased during the early months of the COVID-19 pandemic, some health care providers argue The demands are getting more and more burdensome. Healthcare organizations such as the American Medical Association and the Medical Group Management Association are lobbying Congress for relief.
Now, there is optimism for change. The House of Representatives passed a bill this month It would change the licensing process for Medicare Advantage plans, which serve 28 million Americans and are gaining popularity. US Representative Susan Delbiny sponsored the House of Representatives law Projectcalled “Improving Older People’s Access to Care in Time for Action”.
The bill also has strong support in the Senate, with 42 sponsors.
“I think we have a good chance” in the Senate aisle, said Claire Earnest, director of government affairs for MGMA.
By law, Medicare Advantage plans will be required to tell the centers for Medicare and Medicaid services how often they use pre-authorization and the rate of approvals and refusals. The US Department of Health and Human Services will have to set up a process to make “real-time” decisions for services that are normally approved.
The legislation would also establish an electronic pre-licensing process, something health care organizations have wanted for years.
Even with broad support, the Senate’s passage isn’t closed, simply because there wasn’t much time before Congress ended in January (a factor that influences other healthcare priorities, such as Telehealth reform). Lawmakers will devote much of their attention to the midterm elections in November. Earnest said the bill is likely to be processed after the fall elections.
“I hope by the end of the year we will have passed both houses and sign this bill so we don’t have to do it again,” said Ernst.
While prior authorization has been around for years, doctors said requests are increasing, with a significant amount of time spent seeking approvals for treatments, and then appealing if requests are denied.
Nearly 4 in 5 medical groups (79%) said pre-licensing requirements have increased over the past year, according to a exploratory study By MGMA Released in March.
Most doctors say the process interferes with patient care.
in AMA . survey Released in February, 93% of physicians said the pre-licensing process is delaying patient care. More than four out of five physicians (82%) said that prior authorization sometimes results in patients foregoing the recommended course of treatment. Nearly a third of physicians surveyed (34%) said that delays in obtaining prior authorization had led to adverse events in the patients they were treating.
said Chris Phillips, a rheumatologist in Paducah, Kentucky Chief Healthcare Officer He saw patients give up after denial.
“It’s a heavy time burden for employees,” Phillips said of the pre-authorization process. “It leads to a delay in the treatment of patients.”
Payers say the goal is to ensure patients get appropriate treatment and reduce unnecessary spending, but Phillips said the process limits care.
“It all looks good at 30,000 feet,” he said. “When you’re in a room with a patient, the medical provider receives their medical training for a reason. It’s hard for an impulse to replace our medical decisions from afar.”
“They make the medical decision for us, which is unfortunate,” Phillips said.
Many of his patients suffer from rheumatoid arthritis and autoimmune diseases. While his practice usually does not see life-threatening results when treatment is delayed, patients who do not get timely approval tend to miss work more often.
With rheumatoid arthritis, Phillips said, “the sooner you treat it…the better long-term results will be.”
“Insurers relaxed pre-licensing processes at the height of the pandemic, and we were thankful for that,” Phillips said.
“It’s all over at this point,” he said. “It’s really back to business as usual.”
Doctors also described the frustrating hassles of the authorization process, such as issuing a refusal on Friday and giving them 72 hours to respond, including the weekend. In some circumstances, Phillips said, the motive’s response will arrive on Friday, and the deadline expires on Monday.
In some cases, they will eventually get approval, but not before starting the authorization process all over again.
Ruth Williams, an ophthalmologist in Wheaton, Illinois, recounted some of her headaches with prior permission. Williams said in an interview this spring Chief Healthcare Officer About rejected cataract surgery requests. Some patients have had surgeries cancelled, Williams said.
“They say they agree in 90% of cases,” she said. “If they would agree with 90% of patients, why would they make us go through this exhausting process?”
After pressure from healthcare groups, Aetna announced in July that it She was dropping the pre-authorization requirement for cataract surgeries. When Aetna introduced its pre-authorization policy in 2021, it American Academy of Ophthalmology He said it had an immediate effect. The Academy estimated that 10,000 to 20,000 patients had delayed cataract surgeries in July 2021 alone.
After Aetna rescinded the licensing requirement, Stephen D. MacLeod, chief executive of the American Academy of Ophthalmology, said in a statement that the policy “has been very difficult to understand because the indications for surgery are well established and the benefits are clear.”
“This is an incredibly common procedure, with about 4 million Americans undergoing cataract surgery each year,” he said. “It has a very high success rate in terms of improving safety and eyesight, and studies have consistently shown that cataract surgery improves quality of life, lowers the risk of falls and motor vehicle accidents, and is associated with lower cognitive decline among older adults.”
Even with her experience, Williams said she understands the need for prior permission in some circumstances.
“We’re not saying that prior authorization should be revoked,” Williams said. “She has her role.”
“Pre-authorization as a mechanism, when used appropriately, has a place in health care,” she added. “If someone is using an expensive drug to treat cancer, it could be an assessment of an equally effective cheaper alternative, and that’s fair.”
However, Williams said it is clear that prior authorization must be improved.
“The process does not respect patients and doctors and their schedules,” she said.
“She’s at the top of the list.”
Health care leaders and clinicians have said that requests for prior authorization contribute to burnout, or at least add stress on doctors and health care workers who spend hours on approval and appeal requests.
“There are a million more stabs that lead to exhaustion. This isn’t the biggest one, but it’s at the top of the list,” Phillips said.
Widely Health Affairs Last week’s roundtable on mental health, panel members noted that administrative tasks play a large role in physician burnout. Processes like prior authorization take a lot of time and “make doctors crazy,” said Lawrence Casalino, professor of health care policy and research at Weill Cornell Medical College.
In May, US Surgeon General Vivek Murthy issued a consulting advice Urging healthcare organizations to tackle burnout, reported curtailing prior authorization requests. Among the many recommendations in ReportMurthy suggested “reviewing the volume and requirements for pre-licensing in conjunction with health workers” and “simplifying fax-based work such as pre-licensing for electronic and automated systems.”
Health leaders say too many pre-authorization requests are not being processed electronically. The Council for Quality Healthcare (CAQH) prepares an annual report, and 2021 CAQH Indexwhich measures the progress in dealing with administrative tasks electronically. Pre-authorization is a management function that is lagging behind.
The report found that 26% of pre-authorization requests are handled entirely electronically, and 39% of them were partially electronic. More than a third of prior licenses (35%) were entirely manual, i.e. sent by phone, fax, email or post. “It’s 2022, and even Congress is past faxing,” DelBene, the sponsor of the pre-authorization bill, said on the House floor.
While the pre-authorization bill focuses on Medicare Advantage rather than the entire health care industry, proponents say it would represent a major breakthrough.
Earnest, MGMA’s director of government relations, said advocates are making it clear to Congress that they can help some of America’s most vulnerable patients avoid unnecessary delays in care.
“This appeals to lawmakers on both sides of the aisle,” said Ernst.