Bipartisan Bill Seeks to Curb Use of Prior Authorization in Medicare Advantage

A bill supported by a coalition of physician specialty organizations was introduced in the House of Representatives this week to alleviate the growing use of prior authorizations (PA) in Medicare Advantage (MA). At the same time, the group released survey results saying that PAs are increasing physician burdens and leading to delays in patient care.

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.

The Improving Seniors' Timely Access to Care Act of 2019 (HR 3107) is sponsored by Representatives Suzan DelBene, D-Washington; Mike Kelly, R-Pennsylvania; Roger Marshall, R-Kansas; and Ami Bera, D-California.

“For far too long, patients have faced unnecessary and unreasonable care delays due to insurers’ overzealous use of prior authorization,” said Paula Marchetta, MD, MBA, president of the American College of Rheumatology (ACR), in a statement. “This practice creates significant burdens for physicians and can put patients’ health in jeopardy. We applaud congressional leaders for standing up to ensure America’s Medicare beneficiaries are able to get the care they need and deserve.”

The ACR is part of the Regulatory Relief Coalition, which also 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 prior authorization.

Nearly 75% reported that during the past 5 years, stable patients had been asked to switch medications by a health plan for nonmedical reasons.

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 prior authorization have significantly increased over the past 5 years, with half of all practices reporting 11 or more requests per week.

Although most PAs are eventually approved, the use of the so-called “peer-to-peer” process to obtain a PA seems to be growing; 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. 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.

Besides ACR, the other organizations involved in the coalition are the American Academy of Neurology, American Academy of Ophthalmology, American Association of Neurological Surgeons, Congress of Neurological Surgeons American College of Cardiology, American College of Surgeons, and the American Urological Association.

The bill is also supported by the American Medical Association, American Gastroenterological Association, American Society of Clinical Oncology, Alliance for Specialty Medicine, American College of Physicians, Change Healthcare, Medical Group Management Association, and others.