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  • Congress Focuses On Prior Authorization, Step Therapy

    Inappropriate delays of patient care are getting greater attention thanks to ophthalmology’s champions in Congress, who are shining a light on problems the Academy has brought to their attention.

    Our behind-the-scenes advocacy had an impact Tuesday on a congressional subcommittee hearing on Medicare Advantage. During the hearing, several representatives asked about prior authorization and step therapy obstacles to care for patients — issues we raised based on your ongoing feedback.

    Reps. Kim Schrier, MD, D-Wash.; John Joyce, MD, R-Penn.; Michael Burgess, MD, R-Texas; and Larry Bucshon, MD, R-Ind., all urged passage of the Improving Seniors’ Timely Access to Care Act of 2021. They asked committee leaders to act on this strongly supported bipartisan bill. It has nearly 340 co-sponsors in the House and Senate.

    The oversight subcommittee of the U.S. House Committee on Energy and Commerce heard testimony from leaders of three entities that recently investigated or made new recommendations related to the Medicare Advantage program.

    One of those entities, the Health and Human Services Office of the Inspector General, issued a report in April that raised concerns about inappropriately delayed and denied care under the program. In its report and hearing testimony, the office recommended that the Centers for Medicare & Medicaid Services take several actions. Of these, the Academy and its Regulatory Relief Coalition have pressed CMS to: 

    • Issue new guidance for plans on the appropriate use of prior authorizations; and
    • Address vulnerabilities that can lead to manual review errors and system errors.

    Dr. Joyce, the Pennsylvania congressman, and Rep. Raul Ruiz, MD, D-Calif., also expressed concerns about similarities between prior authorizations and step therapy requirements and their effect on timely access to care for patients. The members spoke on the need to pass legislation that addresses the increased use of step therapy.

    They also asked witnesses about the effect the practices had on patient care. Assistant Inspector General Erin Bliss said her agency’s April report did not investigate the use of step therapy in Medicare Advantage plans. She said they were willing to do a separate report on that cost-cutting strategy.

    The Academy encouraged subcommittee members to raise ophthalmology’s prior authorization and step therapy concerns during the oversight hearing. Addressing these burdens is one of our top advocacy priorities this year, based on what you’ve told us.

    You can continue to support our efforts by telling us how prior authorization and step therapy requirements have affected your patients’ care. Email