Newsflash: Bi-Partisan Agreement on Something! Prior Authorization is Not a “Benefit”

My husband has serious health issues which forced him to retire from medical practice more than a decade ago. When he became eligible for Medicare, someone suggested that he select a Medicare Advantage plan (MA). I said, “Absolutely not.” Yes, we bought an expensive secondary insurance to cover the 20% “patient responsible portion” not covered by traditional Medicare. However, I don’t see how the MA plans save my patients money. One of my current hyperbaric patients is an MA beneficiary and he has a big annual deductible and an out of pocket charge for each HBOT on top of that. That means with Medicare Advantage, he’s paying about the same out of pocket for HBOT as if he had traditional Medicare but carried no secondary insurance. It’s not saving him money. What it did require was weeks of work on our part to get through the MA prior authorization process, and that’s why I didn’t want my husband on an MA plan.

As everyone knows, the milk of human kindness flows through my veins. (Yes, that was a joke because I am so NOT that.) However, I can only tolerate a certain number of “peer to peer” phone calls a day with the various layers of Medicare Advantage bureaucracy in order to get treatments approved for MA beneficiaries – and a lot of times they are still denied. This is a huge problem with cellular products where the MA plans only cover one or two products and they aren’t the ones I use. In other words, the MA plans implement the policies of the private insurance company which may not be the same as Medicare, and you have to jump through hoops to get them. A year or so ago I told you about a Medicare Advantage patient who waited more than 6 months to get a CROW walker approved for a diabetic foot ulcer by her MA plan, with me documenting each time in my notes that her DFU wasn’t healing because she needed a CROW walker. Then her MA plan said she couldn’t keep seeing me because I wasn’t making progress with her wound. You can’t make this up.

Yesterday a bipartisan group of 103 House members lead by Reps. Phil Roe (R-TN) and Ami Bera (D-CA) signed on to a letter asking CMS to tell Medicare Advantage plans not to use prior authorization to inhibit access to services.

I love this quote from their letter:

“It is our understanding that some plans require repetitive prior approvals [PA] for patients that are not based on evidence and may delay medically necessary care. Many of these PA requirements are for services or procedures performed in accordance with an already-approved plan of care, as part of appropriate, ongoing therapy for chronic conditions, or for services with low PA denial rates.

Yep. That is exactly what is happening. The letter asks CMS to issue guidance on the use of prior authorization in order to make sure the requirements don’t create inappropriate barriers to care, and to collect data on the scope of prior authorization use. I wish they would start with wound care, since that’s a multi-billion dollar problem that affects 15% of Medicare beneficiaries,  however, it’s the American Association of Neurological Surgeons and the Congress of Neurological Surgeons that got quoted about their support for the letter

Thankfully, last month CMS Administrator Seema Verma went on record that prior authorization was on her list of issues to tackle.

I completely understand that there has to be a way to address overuse and improper use of expensive therapies. My bias is that QCDR quality measures are the way to handle this since they can be designed to identify “appropriate use” based on specific, well defined parameters. The US Wound Registry has already proven that this approach can work for both cellular products and hyperbaric oxygen therapy. However, since we aren’t (for example) the American Association of Neurological Surgeons, we can’t get traction for this idea. We have zero influence, and there are powerful forces trying to ensure that wound care services continue be as expensive as possible, rather than as efficient as possible. News flash: we are entering the quality era.

However, using appropriate use quality measures would cost much less than prior authorization which is expensive, slow, and highly variable from reviewer to reviewer. Appropriate use quality measures also have consistent criteria and can be automated through any certified EHR. We are talking about trying to be parsimonious with scarce resources. By many estimates, the impending bankruptcy of the Medicare trust fund could be put off many years if all we did was eliminate fraud and abuse, starting with improper use. However, I am sick and tired of using Orwellian Newspeak to discuss these issues. Let’s talk about them honestly. The “Medicare & You” handbook for 2019 put out by CMS suggested that Medicare Advantage plans were cheaper which is simply not true. Furthermore, the handbook described prior authorization as a “right” and an “added benefit!” I am not making this up. Using that logic, we could say that, “an added benefit of infection with the herpes simplex type 2 virus are recurrent genital lesions and the right to a Caesarian section.”

It IS good to see some bipartisan cooperation, and it tells you how really bad this situation must be.