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Major medical, insurance, health groups agree on pre-auth improvement areas
The prior authorization approval process required by health insurance companies for patients’ medical treatments, also called preapproval, eats up countless hours of time and costs, over $80,000 per year, per provider. The average provider deals with 35 of these prior authorization requests per day, and each request takes an average of 20 minutes. Physicians, pharmacists, hospitals, medical groups, and health insurance companies are working together to come up with a solution.
The American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association announced a consensus statement delineating where they agree the health care industry can improve the prior authorization process.
Most of the solutions outlined in the document are intuitive – they include reducing the number of health care professionals subject to prior authorization requirements based on their performance; adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider; reviewing the services and medications that require prior authorization and eliminating requirements for therapies that no longer warrant them; improving communications between health insurance providers, health care professionals, and patients to provide clarity on prior authorization requirements and changes; protecting continuity of care for patients; improving formulary information and coverage restrictions at point-of-care; and adopting national electronic standards for prior authorization.
Jack Resneck Jr., MD, chair-elect of the AMA board of trustees, described the document as a “good initial step” toward reducing the difficulties imposed by prior authorizations.
Prior authorization requests are particularly burdensome for medications that are expensive, a headache that doctors working with patients who have rheumatoid arthritis or lupus know well.
As insurance and provider groups work to improve the prior authorization process “it will be vital that they consider the issue from the perspective of general practitioners as well as specialists, the latter of whom prescribe more of the specialty tier medications that are subject to more protocols before patients can access these often life-improving medications,” Stephen Marmaras, director of policy and advocacy at Global Healthy Living Foundation, said in an interview. “Ultimately, improved communication between both parties – the physician offices and the payers – will allow us to identify barriers existing in current appeals processes and work toward collectively building solutions that benefit patients, particularly those with chronic disease who rely on stable access to medications.”
Sean Fahey, MD, chair of the American College of Rheumatology’s insurance subcommittee, said that, while the consensus statement is “a step in the right direction, like a lot of things, the devil is in the details.
“There’s good concepts in the statement without a whole lot of specifics,” Dr. Fahey said. Most changes will be addressed at the state level, because the federal legislature is very hesitant to legislate decisions for nongovernment insurance.
“A lot of the ideas set forth in this consensus statement are wonderful,” said Dr. Fahey. “Unfortunately for our patients, many of their medications are ludicrously expensive. … Every time you write a prescription for one of these medications, after appropriate therapy, you have to do [a preauthorization] just to get the medicine that people want and need. It’s frustrating that the issue of drug cost is driving the whole process. For a $60,000 a year price you’re going to have to do a preauthorization every single time, as opposed to a drug that’s $100 a year.”
Still, the statement is “an important step” toward ultimately making vital medications “more accessible for patients,” Dr. Fahey said.
The prior authorization approval process required by health insurance companies for patients’ medical treatments, also called preapproval, eats up countless hours of time and costs, over $80,000 per year, per provider. The average provider deals with 35 of these prior authorization requests per day, and each request takes an average of 20 minutes. Physicians, pharmacists, hospitals, medical groups, and health insurance companies are working together to come up with a solution.
The American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association announced a consensus statement delineating where they agree the health care industry can improve the prior authorization process.
Most of the solutions outlined in the document are intuitive – they include reducing the number of health care professionals subject to prior authorization requirements based on their performance; adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider; reviewing the services and medications that require prior authorization and eliminating requirements for therapies that no longer warrant them; improving communications between health insurance providers, health care professionals, and patients to provide clarity on prior authorization requirements and changes; protecting continuity of care for patients; improving formulary information and coverage restrictions at point-of-care; and adopting national electronic standards for prior authorization.
Jack Resneck Jr., MD, chair-elect of the AMA board of trustees, described the document as a “good initial step” toward reducing the difficulties imposed by prior authorizations.
Prior authorization requests are particularly burdensome for medications that are expensive, a headache that doctors working with patients who have rheumatoid arthritis or lupus know well.
As insurance and provider groups work to improve the prior authorization process “it will be vital that they consider the issue from the perspective of general practitioners as well as specialists, the latter of whom prescribe more of the specialty tier medications that are subject to more protocols before patients can access these often life-improving medications,” Stephen Marmaras, director of policy and advocacy at Global Healthy Living Foundation, said in an interview. “Ultimately, improved communication between both parties – the physician offices and the payers – will allow us to identify barriers existing in current appeals processes and work toward collectively building solutions that benefit patients, particularly those with chronic disease who rely on stable access to medications.”
Sean Fahey, MD, chair of the American College of Rheumatology’s insurance subcommittee, said that, while the consensus statement is “a step in the right direction, like a lot of things, the devil is in the details.
“There’s good concepts in the statement without a whole lot of specifics,” Dr. Fahey said. Most changes will be addressed at the state level, because the federal legislature is very hesitant to legislate decisions for nongovernment insurance.
“A lot of the ideas set forth in this consensus statement are wonderful,” said Dr. Fahey. “Unfortunately for our patients, many of their medications are ludicrously expensive. … Every time you write a prescription for one of these medications, after appropriate therapy, you have to do [a preauthorization] just to get the medicine that people want and need. It’s frustrating that the issue of drug cost is driving the whole process. For a $60,000 a year price you’re going to have to do a preauthorization every single time, as opposed to a drug that’s $100 a year.”
Still, the statement is “an important step” toward ultimately making vital medications “more accessible for patients,” Dr. Fahey said.
The prior authorization approval process required by health insurance companies for patients’ medical treatments, also called preapproval, eats up countless hours of time and costs, over $80,000 per year, per provider. The average provider deals with 35 of these prior authorization requests per day, and each request takes an average of 20 minutes. Physicians, pharmacists, hospitals, medical groups, and health insurance companies are working together to come up with a solution.
The American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association announced a consensus statement delineating where they agree the health care industry can improve the prior authorization process.
Most of the solutions outlined in the document are intuitive – they include reducing the number of health care professionals subject to prior authorization requirements based on their performance; adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider; reviewing the services and medications that require prior authorization and eliminating requirements for therapies that no longer warrant them; improving communications between health insurance providers, health care professionals, and patients to provide clarity on prior authorization requirements and changes; protecting continuity of care for patients; improving formulary information and coverage restrictions at point-of-care; and adopting national electronic standards for prior authorization.
Jack Resneck Jr., MD, chair-elect of the AMA board of trustees, described the document as a “good initial step” toward reducing the difficulties imposed by prior authorizations.
Prior authorization requests are particularly burdensome for medications that are expensive, a headache that doctors working with patients who have rheumatoid arthritis or lupus know well.
As insurance and provider groups work to improve the prior authorization process “it will be vital that they consider the issue from the perspective of general practitioners as well as specialists, the latter of whom prescribe more of the specialty tier medications that are subject to more protocols before patients can access these often life-improving medications,” Stephen Marmaras, director of policy and advocacy at Global Healthy Living Foundation, said in an interview. “Ultimately, improved communication between both parties – the physician offices and the payers – will allow us to identify barriers existing in current appeals processes and work toward collectively building solutions that benefit patients, particularly those with chronic disease who rely on stable access to medications.”
Sean Fahey, MD, chair of the American College of Rheumatology’s insurance subcommittee, said that, while the consensus statement is “a step in the right direction, like a lot of things, the devil is in the details.
“There’s good concepts in the statement without a whole lot of specifics,” Dr. Fahey said. Most changes will be addressed at the state level, because the federal legislature is very hesitant to legislate decisions for nongovernment insurance.
“A lot of the ideas set forth in this consensus statement are wonderful,” said Dr. Fahey. “Unfortunately for our patients, many of their medications are ludicrously expensive. … Every time you write a prescription for one of these medications, after appropriate therapy, you have to do [a preauthorization] just to get the medicine that people want and need. It’s frustrating that the issue of drug cost is driving the whole process. For a $60,000 a year price you’re going to have to do a preauthorization every single time, as opposed to a drug that’s $100 a year.”
Still, the statement is “an important step” toward ultimately making vital medications “more accessible for patients,” Dr. Fahey said.
Insulin delivery devices now covered under Part D
Older Americans will now have access to insulin delivery devices under Part D of Medicare coverage, according to guidance issued by the Centers for Medicare & Medicaid Services (CMS). The CMS guidance clarified that devices not previously covered under Medicare Part B will be covered under Part D of the prescription drug program. As a result, older Americans will now have access to a wider range of insulin delivery devices.
Insulin delivery devices help patients manage blood sugar levels effectively. The devices prevent dangerous blood sugar fluctuations that can lead to complications like hypoglycemia.
In the guidance, the CMS wrote: “With the introduction of new insulin delivery devices to the market, questions have arisen about Part D coverage for these products. Specifically, we have been asked whether newer insulin delivery devices that are not covered under Medicare Part B meet the Part D definition of ‘medical supplies associated with the injection of insulin. … The examples that were previously provided were never intended to be an exhaustive list of products that could be covered under Part D. Instead, they represented our understanding of the types of medical supplies associated with the injection of insulin that were available at the time.”
Since then, new delivery devices have been introduced to market “in the form of both mechanical and electronic insulin pumps” that are not covered under the Medicare Part B durable medical equipment (DME) benefit.
“We expect that technology will continue to advance and that ‘medical supplies associated with the injection of insulin’ will become significantly more sophisticated,” wrote the CMS. “As new products become available, Part D sponsors may evaluate these products for formulary placement and medical necessity and, subject to Part D coverage determination and appeals requirements, allow access and restrict use accordingly.”
According to the guidance, Part D will cover supplies “that are alternatives to insulin syringes,” and the CMS will not require insurers who offer Part D plan coverage to include these on their formularies. If these alternatives are included on formularies, sponsors may use utilization management criteria for the products.
In a statement praising the CMS’s decision, the Endocrine Society wrote: “This opens the door for older Americans to gain coverage for devices such as the Omnipod insulin management system, a popular insulin pump system. Until the new guidance was issued, Omnipod was the only FDA [Food and Drug Administration]–approved insulin pump system not covered by Medicare. Previously, people with diabetes who qualified for Medicare at age 65 had to pay out of pocket to continue using the Omnipod, and many lost access to the device.”
Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society, said in an interview that the new CMS guidance "gives physicians and people with diabetes access to a wider range of technology options, since some people with type 1 diabetes prefer the Omnipod’s tubing-free design because it makes it easier to participate in sports and safer to work in certain environments.
“Before this guidance was issued, those patients had to switch pumps or revert to insulin injections when they turned 65 years old. We are pleased this guidance will open the door to greater choice” for patients, said Dr. Lash.
The CMS’s decision on insulin delivery devices follows a decision last year to cover continuous glucose monitors (CGMs) through Medicare. Last week, the CMS also announced it will provide coverage for the Abbott Freestyle Libre CGM, a welcome move for patients seeking additional choices.
This article was revised 1/18/18.
Older Americans will now have access to insulin delivery devices under Part D of Medicare coverage, according to guidance issued by the Centers for Medicare & Medicaid Services (CMS). The CMS guidance clarified that devices not previously covered under Medicare Part B will be covered under Part D of the prescription drug program. As a result, older Americans will now have access to a wider range of insulin delivery devices.
Insulin delivery devices help patients manage blood sugar levels effectively. The devices prevent dangerous blood sugar fluctuations that can lead to complications like hypoglycemia.
In the guidance, the CMS wrote: “With the introduction of new insulin delivery devices to the market, questions have arisen about Part D coverage for these products. Specifically, we have been asked whether newer insulin delivery devices that are not covered under Medicare Part B meet the Part D definition of ‘medical supplies associated with the injection of insulin. … The examples that were previously provided were never intended to be an exhaustive list of products that could be covered under Part D. Instead, they represented our understanding of the types of medical supplies associated with the injection of insulin that were available at the time.”
Since then, new delivery devices have been introduced to market “in the form of both mechanical and electronic insulin pumps” that are not covered under the Medicare Part B durable medical equipment (DME) benefit.
“We expect that technology will continue to advance and that ‘medical supplies associated with the injection of insulin’ will become significantly more sophisticated,” wrote the CMS. “As new products become available, Part D sponsors may evaluate these products for formulary placement and medical necessity and, subject to Part D coverage determination and appeals requirements, allow access and restrict use accordingly.”
According to the guidance, Part D will cover supplies “that are alternatives to insulin syringes,” and the CMS will not require insurers who offer Part D plan coverage to include these on their formularies. If these alternatives are included on formularies, sponsors may use utilization management criteria for the products.
In a statement praising the CMS’s decision, the Endocrine Society wrote: “This opens the door for older Americans to gain coverage for devices such as the Omnipod insulin management system, a popular insulin pump system. Until the new guidance was issued, Omnipod was the only FDA [Food and Drug Administration]–approved insulin pump system not covered by Medicare. Previously, people with diabetes who qualified for Medicare at age 65 had to pay out of pocket to continue using the Omnipod, and many lost access to the device.”
Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society, said in an interview that the new CMS guidance "gives physicians and people with diabetes access to a wider range of technology options, since some people with type 1 diabetes prefer the Omnipod’s tubing-free design because it makes it easier to participate in sports and safer to work in certain environments.
“Before this guidance was issued, those patients had to switch pumps or revert to insulin injections when they turned 65 years old. We are pleased this guidance will open the door to greater choice” for patients, said Dr. Lash.
The CMS’s decision on insulin delivery devices follows a decision last year to cover continuous glucose monitors (CGMs) through Medicare. Last week, the CMS also announced it will provide coverage for the Abbott Freestyle Libre CGM, a welcome move for patients seeking additional choices.
This article was revised 1/18/18.
Older Americans will now have access to insulin delivery devices under Part D of Medicare coverage, according to guidance issued by the Centers for Medicare & Medicaid Services (CMS). The CMS guidance clarified that devices not previously covered under Medicare Part B will be covered under Part D of the prescription drug program. As a result, older Americans will now have access to a wider range of insulin delivery devices.
Insulin delivery devices help patients manage blood sugar levels effectively. The devices prevent dangerous blood sugar fluctuations that can lead to complications like hypoglycemia.
In the guidance, the CMS wrote: “With the introduction of new insulin delivery devices to the market, questions have arisen about Part D coverage for these products. Specifically, we have been asked whether newer insulin delivery devices that are not covered under Medicare Part B meet the Part D definition of ‘medical supplies associated with the injection of insulin. … The examples that were previously provided were never intended to be an exhaustive list of products that could be covered under Part D. Instead, they represented our understanding of the types of medical supplies associated with the injection of insulin that were available at the time.”
Since then, new delivery devices have been introduced to market “in the form of both mechanical and electronic insulin pumps” that are not covered under the Medicare Part B durable medical equipment (DME) benefit.
“We expect that technology will continue to advance and that ‘medical supplies associated with the injection of insulin’ will become significantly more sophisticated,” wrote the CMS. “As new products become available, Part D sponsors may evaluate these products for formulary placement and medical necessity and, subject to Part D coverage determination and appeals requirements, allow access and restrict use accordingly.”
According to the guidance, Part D will cover supplies “that are alternatives to insulin syringes,” and the CMS will not require insurers who offer Part D plan coverage to include these on their formularies. If these alternatives are included on formularies, sponsors may use utilization management criteria for the products.
In a statement praising the CMS’s decision, the Endocrine Society wrote: “This opens the door for older Americans to gain coverage for devices such as the Omnipod insulin management system, a popular insulin pump system. Until the new guidance was issued, Omnipod was the only FDA [Food and Drug Administration]–approved insulin pump system not covered by Medicare. Previously, people with diabetes who qualified for Medicare at age 65 had to pay out of pocket to continue using the Omnipod, and many lost access to the device.”
Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society, said in an interview that the new CMS guidance "gives physicians and people with diabetes access to a wider range of technology options, since some people with type 1 diabetes prefer the Omnipod’s tubing-free design because it makes it easier to participate in sports and safer to work in certain environments.
“Before this guidance was issued, those patients had to switch pumps or revert to insulin injections when they turned 65 years old. We are pleased this guidance will open the door to greater choice” for patients, said Dr. Lash.
The CMS’s decision on insulin delivery devices follows a decision last year to cover continuous glucose monitors (CGMs) through Medicare. Last week, the CMS also announced it will provide coverage for the Abbott Freestyle Libre CGM, a welcome move for patients seeking additional choices.
This article was revised 1/18/18.
Medicaid reform: Work-based waivers may not fly
The Trump administration may not be able to successfully implement the work requirements and other Medicaid eligibility caveats proffered by Health and Human Services Secretary Tom Price, MD, according to Jane Perkins, legal director for the National Health Law Program.
In March, Secretary Price and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, wrote to state governors, letting them know that the HHS would support states’ efforts to increase employment, community engagement, and work requirements for Medicaid recipients. The letter also was supportive of aligning Medicaid benefits with private insurance via alternative benefits, cost-sharing, and premium payments.
High mandatory premiums, cost sharing, lifetime limits, and drug testing “are of concern to us,” Ms. Perkins said at an April 13 press briefing. “They really change the complexion of Medicaid and Medicaid coverage for low-income people.”
These requirements “are not typically seen in Medicaid programs,” she said.
While Section 1115 of the Social Security Act “allows states to test novel approaches to providing medical assistance” via Medicaid waivers, it does not allow the HHS or the states to “ignore congressional mandates; to cut eligibility, services, or provider payments; or to use section 1115 to save money,” according to an issue brief by Ms. Perkins.
When asked how work requirements harm people, Ms. Perkins responded that adding a work requirement to Medicaid eligibility gets things “backwards,” because a sick person needs health care before being able to return to work.
The work requirement would not save states much money, as nearly 8 in 10 adults on Medicaid are in a household that includes a worker and 59% of recipients work themselves, according to a Kaiser Family Foundation study. The adults affected by the work requirement would make up only a drop in the ocean of Medicaid spending. About two-thirds of that spending goes toward senior citizens, people with disabilities, children, and people in long term care, according to projections from the Congressional Budget Office.
The National Health Law program, which advocates for low-income Medicaid recipients, is following the waivers state-by-state with a network of lawyers who work with people with disabilities in each state.
“With this new openness to flexibility, we are certainly watching what is going on in the states,” Ms. Perkins said.
The Trump administration may not be able to successfully implement the work requirements and other Medicaid eligibility caveats proffered by Health and Human Services Secretary Tom Price, MD, according to Jane Perkins, legal director for the National Health Law Program.
In March, Secretary Price and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, wrote to state governors, letting them know that the HHS would support states’ efforts to increase employment, community engagement, and work requirements for Medicaid recipients. The letter also was supportive of aligning Medicaid benefits with private insurance via alternative benefits, cost-sharing, and premium payments.
High mandatory premiums, cost sharing, lifetime limits, and drug testing “are of concern to us,” Ms. Perkins said at an April 13 press briefing. “They really change the complexion of Medicaid and Medicaid coverage for low-income people.”
These requirements “are not typically seen in Medicaid programs,” she said.
While Section 1115 of the Social Security Act “allows states to test novel approaches to providing medical assistance” via Medicaid waivers, it does not allow the HHS or the states to “ignore congressional mandates; to cut eligibility, services, or provider payments; or to use section 1115 to save money,” according to an issue brief by Ms. Perkins.
When asked how work requirements harm people, Ms. Perkins responded that adding a work requirement to Medicaid eligibility gets things “backwards,” because a sick person needs health care before being able to return to work.
The work requirement would not save states much money, as nearly 8 in 10 adults on Medicaid are in a household that includes a worker and 59% of recipients work themselves, according to a Kaiser Family Foundation study. The adults affected by the work requirement would make up only a drop in the ocean of Medicaid spending. About two-thirds of that spending goes toward senior citizens, people with disabilities, children, and people in long term care, according to projections from the Congressional Budget Office.
The National Health Law program, which advocates for low-income Medicaid recipients, is following the waivers state-by-state with a network of lawyers who work with people with disabilities in each state.
“With this new openness to flexibility, we are certainly watching what is going on in the states,” Ms. Perkins said.
The Trump administration may not be able to successfully implement the work requirements and other Medicaid eligibility caveats proffered by Health and Human Services Secretary Tom Price, MD, according to Jane Perkins, legal director for the National Health Law Program.
In March, Secretary Price and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, wrote to state governors, letting them know that the HHS would support states’ efforts to increase employment, community engagement, and work requirements for Medicaid recipients. The letter also was supportive of aligning Medicaid benefits with private insurance via alternative benefits, cost-sharing, and premium payments.
High mandatory premiums, cost sharing, lifetime limits, and drug testing “are of concern to us,” Ms. Perkins said at an April 13 press briefing. “They really change the complexion of Medicaid and Medicaid coverage for low-income people.”
These requirements “are not typically seen in Medicaid programs,” she said.
While Section 1115 of the Social Security Act “allows states to test novel approaches to providing medical assistance” via Medicaid waivers, it does not allow the HHS or the states to “ignore congressional mandates; to cut eligibility, services, or provider payments; or to use section 1115 to save money,” according to an issue brief by Ms. Perkins.
When asked how work requirements harm people, Ms. Perkins responded that adding a work requirement to Medicaid eligibility gets things “backwards,” because a sick person needs health care before being able to return to work.
The work requirement would not save states much money, as nearly 8 in 10 adults on Medicaid are in a household that includes a worker and 59% of recipients work themselves, according to a Kaiser Family Foundation study. The adults affected by the work requirement would make up only a drop in the ocean of Medicaid spending. About two-thirds of that spending goes toward senior citizens, people with disabilities, children, and people in long term care, according to projections from the Congressional Budget Office.
The National Health Law program, which advocates for low-income Medicaid recipients, is following the waivers state-by-state with a network of lawyers who work with people with disabilities in each state.
“With this new openness to flexibility, we are certainly watching what is going on in the states,” Ms. Perkins said.