Health groups say the approval requests are delaying patient care and stressing overworked staff. Proponents say a bill to revamp the Medicare Advantage Plan process would help millions of people.
Physicians and other health care advocates have denounced the preapproval process for years, but some see an opportunity for reform.
Members of Congress are pushing legislation to streamline the pre-approval process for Medicare Advantage plans used by millions of seniors. Pre-approval requires doctors and clinics to obtain approval from insurance companies for certain medications and treatments.
Insurers claim preapproval is designed to reduce unnecessary treatment and wasteful spending, but doctors say the process is too demanding and causes patients to be denied medication. They also say they are sucking time from already overworked and understaffed health care workers, adding that they are a major cause of burnout.
While some say demand eased in the early months of the COVID-19 pandemic, some health care providers claim demand has become more burdensome. Medical organizations such as the American Medical Association and the Medical Group Management Association have sought relief from Congress.
Now there is optimism for change. The House of Representatives passed a bill this month that would change the approval process for the increasingly popular Medicare Advantage Plans, which serve 28 million Americans. U.S. Representative Susan Delvene (D-Wash.) was the sponsor of a House bill called “Improving Timely Access to Elderly Care and Action.”
The bill also has strong support in the Senate, with 42 cosponsors.
“I think we have a good shot,” said Claire Ernst, MGMA’s director of government affairs.
Under the bill, Medicare Advantage plans would have to tell the Centers for Medicare and Medicaid Services how often they are using preapproval and the rate of approvals and denials. Processes should be in place to make “real-time” decisions about the services being delivered.
The law also establishes an electronic pre-approval process that medical institutions have long wanted.
Even with broad support, Senate passage isn’t a lock, simply because there isn’t much time left before Congress ends in January (factors that will affect other healthcare priorities, such as telemedicine reform). ). Members of Congress will be paying a lot of attention to the November midterm elections. Ernst said the bill would likely be taken up after the autumn elections.
“We hope to have it passed by both chambers and signed into law by the end of the year,” Ernst said.
“heavy burden”
While advance approval has been around for years, doctors say demand is on the rise, with considerable time spent seeking approval for treatment and appeals if the request is denied. rice field.
According to an MGMA survey released in March, nearly four-fifths (79%) of medical groups said pre-approval requirements had increased in the past year.
Most doctors say this process interferes with patient care.
An AMA survey released in February found that 93% of physicians said the pre-approval process leads to delays in patient care. More than four in five of her physicians (82%) said prior approval may cause patients to waive recommended treatment regimens. Nearly one-third (34%) of physicians surveyed said delays in pre-approval caused adverse events for patients on treatment.
Chris Phillips, a rheumatologist in Paducah, Kentucky, said: chief medical officer He has seen patients give up after denial.
“It’s a huge time burden for staff,” Phillips said of the pre-approval process. “It leads to delays in patient care.”
Payers say the goal is to ensure patients get the right care and limit unnecessary spending, but Phillips said the process limits care.
“It all sounds good at 30,000 feet,” he said. “For some reason, providers have medical training when they are in the same room as a patient. It is difficult for payers to replace our medical decisions from afar.”
“They are making medical decisions for us, which is unfortunate,” Phillips said.
Many of his patients suffer from rheumatoid arthritis and autoimmune diseases. In his practice, delays in treatment typically do not show life-threatening consequences, but patients who do not receive timely approval tend to be out of work.
For rheumatoid arthritis, “the sooner you treat it, the better the long-term outcome,” Phillips said.
Phillips said insurers had eased pre-approval processes at the height of the pandemic, and was “thankful for that.”
“At this point, it’s all gone,” he said. “It’s really back to business as usual.”
Doctors also described frustrating hassles in the approval process, such as being denied on Friday and having to respond within 72 hours, including weekends. In some circumstances, payer responses may arrive on Friday and expire on Monday, he said.
In some cases, you can finally get approval, but not before starting the approval process all over again.
‘Troublesome procedure’
With prior permission, Ruth Williams, an ophthalmologist in Wheaton, Illinois, detailed some of her headaches. chief medical officer Regarding the rejected request for cataract surgery. Some patients have canceled surgeries, Williams said.
“They say they approve 90 percent of cases,” she said. “If they are going to approve 90% of patients, why are they forcing us to go through such a cumbersome process?”
Following pressure from healthcare groups, Aetna announced in July that it would remove the pre-approval requirement for cataract surgery. When Aetna introduced his preapproval policy in 2021, the American Academy of Ophthalmology said it had an immediate impact. The Academy estimates that in July 2021 alone, he postponed cataract surgery between 10,000 and 20,000 patients.
After Aetna withdrew its clearance requirements, Stephen D. McLeod, chief executive officer of the American Academy of Ophthalmology, said in a statement, “The indications for surgery are well established and the benefits are clear. It was very difficult to understand the policy,” he said.
“It’s a very common procedure with about 4 million Americans undergoing cataract surgery each year,” he said. “With very high success rates in terms of safety and improved vision, cataract surgery is associated with improved quality of life, lower risk of falls and motor vehicle accidents, and reduced cognitive decline in older adults. Studies consistently show that
Williams said she understands, given her experience, that prior approval is necessary in some situations.
“We’re not saying pre-approval should be eliminated,” Williams said. “It has a role.”
“Pre-approval as a mechanism, if used properly, will play an important role in the healthcare field,” she added. “If someone is using an expensive drug to treat cancer, it could be an evaluation of an equally effective and cheaper alternative, and that’s fair.”
But Williams said it was clear that pre-approval had to be improved.
“This process is not respectful of patients and doctors and their schedules,” she said.
“High on the list”
Healthcare leaders and physicians say prior approval requests lead to burnout or, at the very least, stress for doctors and healthcare workers who spend hours on approval requests and appeals.
“There are a million other stings that lead to burnout. It’s not the biggest, but it’s high on the list,” Phillips said.
Abroad health problems At last week’s roundtable on mental health, panelists noted that administrative work plays a big role in physician burnout. Lawrence Casarino, a professor of health policy and research at Weill Cornell School of Medicine, said processes such as pre-approval take a lot of time and “drive doctors crazy.”
In May, U.S. Surgeon General Vivek Murthy issued a recommendation urging healthcare providers to address burnout, noting a reduction in preapproval requirements. Among the report’s many recommendations, Murthy said, “Consider the amount and requirements of pre-approval with health care professionals,” and “Fax-based work, such as pre-approval for electronic and automated systems. ‘to rationalize the
Too many pre-approval requests are not being processed electronically, medical officials say. The Council for Affordable Quality Healthcare (CAQH) is compiling his 2021 CAQH Index, an annual report. It electronically measures progress in processing administrative tasks. Pre-approval is one administrative feature that has lagged behind.
According to the report, 26% of previous approval requests were processed fully electronically, and 39% of approvals were partially processed electronically. Over a third (35%) of previous approvals were submitted entirely manually, by phone, fax, email, or mail. “It’s 2022, and even Congress is moving beyond sending faxes,” DelBene, his sponsor of the previous approval bill, said on the House floor.
Previous approval bills focused on Medicare Advantage rather than the healthcare industry as a whole, but supporters still say it represents a significant achievement.
Advocates are making it clear to Congress that it can help some of America’s most vulnerable patients avoid unnecessary delays in treatment, said Ernst, MGMA’s director of government relations.
“It appeals to lawmakers on both sides of the aisle,” said Ernst.
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