SHM Joins Multi-Stakeholder Letter on Prior-Authorization

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The Honorable Seema Verma

Administrator

Centers for Medicare & Medicaid Services

U.S. Department of Health and Human Services

Hubert H. Humphrey Building, Room 445-G

200 Independence Avenue, SW Washington, DC  20201

 

Dear Administrator Verma:

The undersigned physician organizations support the Centers for Medicare & Medicaid Services’ (CMS) Patients Over Paperwork initiative and applaud CMS for tackling the challenging issue of prior authorization (PA) as part of your efforts to reduce administrative burdens in health care. Physician practices report completing an average of 31 PAs per physician per week. This workload consumes 14.9 hours (nearly 2 business days) each week of physician and staff time and reflects time that would be better spent with patients. More importantly, PA is negatively impacting patient care. Over one-quarter (28%) of physicians report that PA has led to a serious adverse event (e.g., disability, hospitalization, death) for a patient in their care.

We do, however, have strong concerns that CMS may be focusing on automation as the only vehicle for implementing PA reforms. We are aware that CMS has invested heavily in the Da Vinci Project, which leverages technology to facilitate electronic exchange of clinical data by extracting information from physicians’ electronic health records (EHRs). While Da Vinci holds promise, there are a series of issues with exclusively relying on technology to address the burdens of PA. For example, solely concentrating on process automation may set the stage for increased PA volume because document exchange will be easier and faster. Patient care delays will continue, as manual review of medical documentation is often required following the instantaneous electronic exchange of data. Furthermore, Da Vinci will allow payers unprecedented access to EHRs. Protections are needed to prevent plans from inappropriately accessing patient information, coercing physicians into using technology (e.g., through contracts), or interfering with medical decision making. Lastly, Da Vinci represents nascent technologies that have yet to be widely implemented. Therefore, the costs and the timeframe availability across EHR vendors remain unclear. Of considerable concern, Da Vinci likely will not offer relief from PA for small practices in the near future.

Automation is important, but it reflects only one of five major reforms we believe are needed to address the significant problems caused by PA. While we understand there may be a role for PA, we believe it must be right-sized and used judiciously. We strongly urge CMS to implement a comprehensive strategy to reduce the harms and burdens of PA by facilitating payer adoption of the following principles:

• Selective application of PA to only “outliers”;
• Review/adjustment of PA lists to remove services/drugs that represent low-value PA;
• Transparency of PA requirements and their clinical basis to patients and physicians;
• Protections of patient continuity of care; and
• Automation to improve PA and process efficiency.

We would welcome the opportunity to work with CMS to identify ways technology can help advance all of these reform goals. Under your guidance, CMS could be the leader that is critically needed to address the problematic issue for patients and physicians of PA.

Sincerely,

American Medical Association

Academy of Physicians in Clinical Research

American Academy of Dermatology Association

American Academy of Facial Plastic and Reconstructive

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Orthopaedic Surgeons

American Academy of Otolaryngic Allergy

American Academy of Otolaryngology- Head and Neck Surgery

American Academy of Sleep Medicine

American Association of Clinical Urologists

American Association of Hip and Knee Surgeons

American Association of Neurological Surgeons

American College of Allergy, Asthma and Immunology

American College of Emergency Physicians

American College of Obstetricians and Gynecologists

American College of Osteopathic Internists

American College of Osteopathic Surgeons

American College of Physicians

American College of Radiation Oncology

American College of Radiology

American College of Rheumatology

American Gastroenterological Association

American Medical Women’s Association

American Society for Dermatologic Surgery Association

American Society for Gastrointestinal Endoscopy

American Society for Radiation Oncology

American Society of Anesthesiologists

American Society of Cataract & Refractive Surgery

American Society of Dermatopathology

American Society of Echocardiography

American Society of Hematology

American Society of Interventional Pain Physicians

American Society of Neuroradiology

American Society of Plastic Surgeons

American Society of Retina Specialists

American Urological Association

Association of Academic Physiatrists

Association of University Radiologists

College of American Pathologists

Congress of Neurological Surgeons

Heart Rhythm Society

International Society for the Advancement of Spine Surgery

Medical Group Management Association

North American Spine Society

Outpatient Endovascular and Interventional Society

Society for Cardiovascular Angiography and Interventions

Society of Cardiovascular Computed Tomography

Society of Critical Care Medicine

Society of Hospital Medicine

Society of Interventional Radiology

Society of Thoracic Surgeons

Spine Intervention Society

Medical Association of the State of Alabama

Arizona Medical Association

Arkansas Medical Society

California Medical Association

Colorado Medical Society

Connecticut State Medical Society

Medical Society of Delaware

Medical Society of the District of Columbia

Florida Medical Association Inc

Medical Association of Georgia

Hawaii Medical Association

Idaho Medical Association

Illinois State Medical Society

Iowa Medical Society

Kansas Medical Society

Kentucky Medical Association

Louisiana State Medical Society

Maine Medical Association

MedChi, The Maryland State Medical Society

Massachusetts Medical Society

Michigan State Medical Society

Minnesota Medical Association

Mississippi State Medical Association

Missouri State Medical Association

Montana Medical Association

Nebraska Medical Association

Nevada State Medical Association

New Hampshire Medical Society

Medical Society of New Jersey

New Mexico Medical Society

Medical Society of the State of New York

North Dakota Medical Association

Ohio State Medical Association

Oklahoma State Medical Association

Oregon Medical Association

Pennsylvania Medical Society

Rhode Island Medical Society

South Carolina Medical Association

South Dakota State Medical Association

Tennessee Medical Association

Texas Medical Association

Utah Medical Association

Vermont Medical Society

Medical Society of Virginia

Washington State Medical Association

West Virginia State Medical Association

Wisconsin Medical Society

Wyoming Medical Society