370 healthcare organizations urge Congress to protect MA patients from prior authorization

Medicare Advantage
Hundreds of healthcare groups urged Congress to pass a law to reform the prior authorzation process for Medicare Advantage patients. (Getty/designer491)

Hundreds of healthcare groups sent a letter to Congress this week urging lawmakers to pass a bill to protect growing numbers of Medicare Advantage (MA) beneficiaries from prior authorization requirements.

The 10-page letter—it took nine pages to include the names of 370 organizations—urged the passage of a bipartisan bill to reform prior authorization requirements that can delay or deny MA patients’ access to care.

The letter (PDF) was signed by leading physician, patient, healthcare professional and other stakeholder organizations including the American Medical Association (AMA) and the Medical Group Management Association.

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“The demand and need for such reforms is growing—particularly as more seniors choose MA for their health insurance needs,” the groups told members of Congress.

They urged lawmakers to pass what is known as the Improving Seniors’ Timely Access to Care Act of 2019, which was recently introduced by Reps. Suzan DelBene, D-Washington; Mike Kelly, R-Pennsylvania; Roger Marshall, M.D., R-Kansas; and Ami Bera, M.D., D-California.

“This bipartisan legislation would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors,” the groups wrote.

RELATED: Industry Voices—Prior authorizations frustrate physicians. In radiology, denials can be life-threatening

The legislation would make it easier for patients to access treatments by requiring the Centers for Medicare & Medicaid Services (CMS) to regulate the use of prior authorization by MA plans. The bill would facilitate electronic prior authorization and improve transparency for beneficiaries and providers by mandating that health insurance plans report to CMS their prior authorization usage rate and the frequency with which they approve or deny coverage.

Also among the groups signing the letter was the American College of Rheumatology (ACR), a medical association for rheumatologists and rheumatology health professionals that has advocated for reducing regulatory burdens in the Medicare program to assure patients have access to timely and medically necessary treatment.

"While intended to control costs, the unregulated use of prior authorization has devolved into a time-consuming and obstructive process that often stalls or outright revokes patient access to medically necessary therapies,” Paula Marchetta, M.D., president of ACR, said in a statement.

“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. Patients, physician groups, hospital associations, and other key stakeholders all agree that reform is needed,” she said.

Prior authorizations have long been a pain point for physicians. Doctors and health insurance plans have battled over how to reform the prior authorization process. In 2018, six leading health industry groups released a consensus statement outlining steps for improvement, but physicians remain frustrated with a lack of progress.

A survey by the AMA found about a quarter of physicians feel the prior authorization process required by health insurers for certain drugs, tests and treatments has led to serious or life-threatening adverse events for patients such as hospitalization or permanent damage.

More than 9 in 10 physicians (91%) said that prior authorization programs have a negative impact on patient clinical outcomes.

In calling for changes for the MA program, the healthcare groups cited an analysis by the nonprofit Kaiser Family Foundation that found 22 million Medicare beneficiaries, more than one-third of the total enrollment, have an MA plan. Insurers have been steadily flocking to MA plans, and the Congressional Budget Office projects enrollment will rise by 47% by 2029.

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