House committee throws spotlight on prior authorization burden


Physician associations on Wednesday called on U.S. House of Representatives lawmakers to pass legislation to streamline prior authorization, claiming it places undue burden and costs on physicians.

During a hearing before the House Committee on Small Business, four doctors representing physician associations said onerous prior authorization requirements delay necessary patient care, lead to burn out in physicians and result in worse outcomes.

“The prior authorization process is out of control. It is increasing and rather than a tool for preventing unnecessary or expensive care, prior authorizations negatively impact my patients’ health and is a significant cause for family physician burnout and the closure of small private practices,” Dr. John Cullen, a family doctor representing the American Academy of Family Physicians, told the committee.

Cullen, who practices at the Valdez Medical Clinic in Alaska, described the “chaos” of having to deal with 35 different health insurers that all have their own prior authorization processes and drug formularies that change regularly, making it hard to know in advance what services and medications will be covered.

“My patients rarely blame insurance company for this,” he said. “They blame me for not giving them the medications they need, yell at my staff or just stop taking the medications they need to prevent hospitalization.”

Dr. Howard Rogers, a dermatologist who owns a small private practice in Connecticut, said his practice spends 70 hours a week on prior authorization. He hired two full-time staff to handle the volume of prior authorizations, costing him $120,000 in salary and benefits that could have been spent on staff education, improved benefit packages for employees and new medical equipment and technology.

“One-quarter of all communications in my office, be it phone calls, faxes, emails, EMR notifications, payer portals—they are all associated with prior authorizations, and the kicker is that most of my patients prescriptions and repairs eventually get approved, but only after exhaustive efforts of calling insurers and appealing denials,” Rogers said, testifying on behalf of the American Academy for dermatology association.

Dr. Paul Harari, chairman of the department of human oncology at the University of Wisconsin School of Medicine and Public Health and chairman of American Society for Radiation Oncology, explained in his testimony that prior authorization reviewers employed by health insurers are often not in the same specialty are are unfamiliar with the condition or prescribed treatment.

Harari pointed out that HHS Office of the Inspector General in 2018 said Medicare Advantage insurers may have incentive to deny prior-authorization requests to increase profits.

Committee members seemed receptive to the doctors’ calls for relief.

“You go out and do all this education, training, put years and years at work to prepare for patients and then you go to do the work and you have to ask permission every step of the way,” Rep. John Joyce, (R-Penn.), said during the hearing. “So whatever we can do in order to make it possible to do your job we’ll support you 100%, (and) think we’ll support that bill you’re talking about.”

That bill is called the “Improving Seniors’ Timely Access to Care Act of 2019” and was introduced in June.

More than 370 groups including the Federation for American Hospitals and the American Medical Association — along with a slew of other physician groups — signed on this week to a letter of support for the bill by Reps. Suzan DelBene (D-Wash.) and Roger Marshall (R-Ky.).

The American Hospital Association didn’t sign onto the general letter, but the group’s executive vice president Tom Nickels sent an endorsement last month to the legislation’s cosponsors.

The bill would still need committee approval before it could move to the floor. It’s still unclear, with a crowded schedule for healthcare policy this year, when that hearing would happen.

And while there’s no public opposition to the bill as currently drafted, sources close to discussion say the Blue Cross and Blue Shield Association isn’t happy with it.

In a joint statement about the hearing on Wednesday, insurance industry lobbying groups America’s Health Insurance Plans and the Blue Cross and Blue Shield Association said health insurers are committed to reducing unnecessary burden by streamlining the prior authorization process and are working with other stakeholders to do that.

But they warned against legislation.

“Statutory restrictions on medical management will hinder the ability of these tools to address both existing areas of continued misuse as well as future areas yet to be identified,” the groups said.

One of the unresolved areas for a few insurers, according to sources, is what they’d have to publish on their website for their Medicare patients to see.

These include a list of all treatments or items that patients would need prior-authorization for, the percentage of prior-authorization requests the insurer had approved the previous plan year, and the percentage of denials for treatment.

Plans would also have to submit this information to HHS, but the hang-up according to those close to negotiations is putting it out in public.

Peggy Tighe of the Washington law firm Powers, Pyles, Sutter & Verville who has lobbied both the administration and Congress on this issue over the past two years, blasted this idea.

“The opposition as I understand it to the transparency element of this is based on patients being able to know how the MA insurers use prior (authorization) to deny care,” she said. “And to us that’s indefensible.”

The lobbying push for ground rules to stop treatment delays started early in the Trump administration. Medicare Advantage prior authorization headaches featured prominently in comment letters to the CMS for its Medicare red-tape relief project.

Then in January, prominent insurers and insurer groups including America’s Healthcare Plans and BCBSA signed onto a consensus statement with doctor and hospital groups, which started as the baseline for legislative language.

The language as currently written streamlines and loosens prior-authorization requirements for only “medically necessary” procedures—and especially those that could lead to a critically ill patient getting sicker—to try to stop treatment delays.

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