• Stopping Delays in Care and Ending Medicare’s Burdens on Practices


    What we told you early this year

    The Academy had a clear mandate to stop policies that delay our patients’ timely access to care. We put a bullseye on how Medicare Advantage plans are deploying two tools that they say help reduce costs, but in reality, put our patients at risk by making them wait for critical treatments. These tools are prior authorization and step therapy.

    What’s happening today

    Rep. Kelly
    Robert F. Haverly, MD, right, stands with Rep. Mike Kelly, R-Pa., one of the authors of legislation that would halt Medicare Advantage plans’ abusive use of prior-authorization.

    We made a lot of noise on Capitol Hill about prior authorization and step therapy during the Academy’s Congressional Advocacy Day in April. In a breakthrough two years in the making, Congress is taking action to halt prior authorization abuses by Medicare Advantage plans. Bipartisan legislation introduced in June would require the Centers for Medicare & Medicaid Services to rein in these plans and bring transparency to how prior authorization is used. It took the Academy’s coalition of eight physician organizations and a compelling set of data showing prior authorization’s effect on patient care, but we got there. We’re now building momentum to ensure this bill’s passage in Congress.

    Step therapy is more complicated. Many congressional staffers don’t understand how it works or its effect. We need patient stories to put a face to a policy that we know is bad. We’re challenging the legality of the policy because we believe CMS does not have the authority to permit Medicare Advantage plans to implement fail-first policies. The Academy is basing this argument on the fact that this obstacle to care does not exist in Medicare fee-for-service.

    Prior Authorization Reform

    On June 5, two U.S. House Democrats – Suzan DelBene of Washington state and Ami Bera, MD, of California – and two House Republicans – Mike Kelly of Pennsylvania and Roger Marshall, MD, of Kansas – introduced the Improving Seniors' Timely Access to Care Act of 2019 (HR 3107).

    The bill would improve the prior authorization process by requiring the Centers for Medicare & Medicaid Services to regulate when and how Medicare Advantage plans use this cost management tool. The bill includes an important surgical exception that would allow surgeons to rely on the initial insurance authorization if they need to perform additional services while the patient is in surgery. Finally, it would bring greater transparency to prior authorization by requiring Medicare Advantage plans to report to CMS on the extent of their use of it and the rate of approvals or denials by service and prescription medication.

    To get to this point, we had to first build a coalition. The Academy-led Regulatory Relief Coalition spans medicine, counting urology, rheumatology and cardiology among our friends. We took what our members gave us – compelling evidence on the extent to which prior authorization can delay patients’ access to medically necessary care, along with the unnecessary burdens prior authorization places on physicians – and told everyone who would listen. That included the White House, CMS and the plans themselves. When no action was taken, we went to Congress. They agreed to act.

    The Regulatory Relief Coalition released a statement about our support for this legislation and the results of our multi-specialty physician survey, which details the negative effects of excessive prior authorization use.

    You can help us build congressional support for the Improving Seniors’ Timely Access to Care Act. Use the Academy’s advocacy tool to contact your U.S. representatives to urge them to co-sponsor the legislation.

    Step Therapy

    We have a wealth of new information that further reinforces the threat that step therapy represents for our patients.

    First, how step therapy is being defined is beyond troubling. One Medicare Advantage plan serving Idaho, Montana and Oregon defines an anti-VEGF drug’s failure as resulting in patients’ worsening vision after a minimum three-month trial, “such as losing greater than 15 letters of visual acuity.”

    At least five other Medicare Advantage Plans in 2019 are implementing step therapy to curtail physicians’ first choice for patients’ treatment. Many requirements for intravitreal anti-VEGF therapy are similarly egregious. Some require three months of failed treatment before the physician can administer a different drug.

    In May, the CMS issued a final rule that codefies the use of these “fail-first” therapies in Medicare in 2020. In response to concerns raised by the Academy and others, CMS put in place some modest consumer protections, including limiting step therapy to new patient cases. CMS’ final rule – which take effect in 2020 – codifies directions on when step therapy can be used, as well as how it is reviewed and approved.

    Among the more positive changes is a longer look-back period for establishing what qualifies as patients’ new start of treatment.

    CMS also established the following patient protections, based on input from the Academy and others:

    • Step therapy may only be applied to new starts of medication.
    • Medicare Advantage plans will be required to administer new, shorter time frames for step therapy determinations. The appeals process will also be similar to how coverage determination challenges are managed in Medicare Part D.
    • Step therapy lists must be reviewed and approved by plans’ pharmacy-and-therapeutics committees that include physicians and pharmacists.
    • Beginning in 2020, savings that result from step therapy must be reflected in the plans’ premiums or additional benefits to patients. This would take the form of either additional supplemental benefits, lower premiums, or both. Plans have the option of offering beneficiary rewards and incentive programs (though they do not have to) through a drug management program.
    • To minimize administrative burdens and process challenges for providers, CMS expects Medicare Advantage plans to work closely with providers to adopt best practices that streamline requirements to prevent new burdens.
    • Plans cannot use step therapy to deny medically necessary care.

    CMS also says it will allow providers to receive plans’ permission to bypass the step therapy requirement by requesting preservice plan decisions. The agency also committed to monitoring beneficiary complaints and organizational determinations, with appeals facilitated by a Part C Independent Review Entity contractor.

    Use this website to alert the Academy on how health plans use step therapy to delay your patients’ medically necessary care. We’re not just looking for Medicare cases. We’re equally interested in understanding how commercial plans’ use of step therapy has affected our patients.