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Regulatory relief for gastroenterologists

AGA position: AGA seeks regulatory relief for gastroenterology practices to enhance patient care.

Background

Physicians continue to be burdened with onerous regulations and requirements from Medicare and other payors that take time away from patient care, are costly to their practices, and often have no benefit to improving patient care and outcomes. AGA urges the Centers for Medicare & Medicaid Services (CMS), other payors and Congress to provide relief to physicians in the following areas.

Prior authorization

Physicians are subject to prior authorization from most payors. Prior authorization — a medical management tool used by payors to ensure appropriate patient care and control costs — is tremendously burdensome to physicians and physician practices, and often interrupts and/or delays delivery of patient care. 

The services subject to prior authorization vary by payor, but also by plan type within a given payor. With each payor having hundreds, and in some cases thousands, of plans, physicians and physician practices are forced to comply with an increasing and unmanageable number of prior authorization requirements. Additionally, most payor requirements are neither transparent nor easily accessible. AGA urges payors to standardize prior authorization requirements and criteria, and make them transparent and easily accessible. Payors should proactively work to reduce prior authorization requirements to minimize physician administrative burden. AGA also encourages CMS to require a standardized and streamlined prior authorization process by Medicare Advantage and Part D plans. Additionally, approved prior authorizations should be valid for a minimum of one year. 

Finally, prior authorization requests are not always reviewed by payor medical directors or other physicians employed by payors. Medical treatment decisions should not be made by non-physician medical staff. AGA urges payors, including CMS, to develop and implement processes that allow for true “peer-to-peer” dialogues. Gastroenterologists seeking prior authorization for prescription drug or biologic therapy on behalf of a patient should be routed to a physician specialist in the same or similar discipline with expertise in the given condition to discuss the request; not a general nurse, pharmacist or other allied health professional who is unfamiliar with the disease processes and care management.

AGA supports the Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173) introduced by Sens. Roger Marshall, MD (R-KS), Krysten Sinema (D-AZ), John Thune (R-SD) and Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, MD (D-CA), and Larry Bucshon, MD (R-IN). This legislation aims to increase transparency and accountability of Medicare Advantage plans and streamline the prior authorization process by: 

  • Establishing an electronic prior authorization process. 
  • Minimizing the use of prior authorization for services that are routinely approved. 
  • Ensuring prior authorization requests are reviewed by qualified medical personnel. 
  • Requiring plans to report on the extent of their use of prior authorization and the rate of delays and denials.  

 

Step therapy

Patients, including those with digestive diseases such as Crohn’s disease and ulcerative colitis, are often subject to step therapy policies, also known as “fail first,” which occur when an insurer requires patients to try and fail one or more lower-cost prescription drug or biologic therapies before covering the therapy originally prescribed by their health care provider. Step therapy may also require patients to try a certain class or classes of drugs or biologics before another may be used. These policies deny coverage for safe and effective medications simply because they cost more. Such policies fail to consider the unique needs of specific patients. This practice is burdensome for the physician and patient. In some instances, appeals of step therapy policies can take months to resolve putting patients at risk for poor health outcomes and jeopardizing the physician-patient relationship. Some physician practices have a full-time employee devoted to navigating this process for patients, but not all practices have the resources to devote to this administrative burden. AGA urges insurers to reduce the burden of step therapy on physicians and physician practice. One step may be to incorporate step therapy approval and override processes into their prior authorization forms and procedures. Consolidation of step therapy and prior authorization processes would help reduce the administrative burden that physicians and physician practices face.  

AGA supports the Safe Step Act (S. 464/H.R. 2163) introduced by Sens. Lisa Murkowski (R-AK), Maggie Hassan (D-NH), Bill Cassidy, MD (R-LA) Jacky Rosen (D-NV) and Reps. Raul Ruiz, MD (D-CA), Brad Wenstrup, DPM (R-OH), Lucy McBath (D-GA), Mariannette Miller-Meeks, MD (R-IA). This legislation provides a clear and timely appeals process when a patient is subjected to step therapy and outlines five exceptions to fail first protocols. Importantly, it requires insurers to respond to an exemption request within 72 hours under normal circumstances, and within 24 hours if life threatening. 

Reviewed: May 2022

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