Rheumatologists Urge HHS to Revise Medicare Prior Authorization


The American College of Rheumatology said a recent Medicare rule may affect prescription drug access.

The American College of Rheumatology (ACR) recently responded to a Request for Information on Promoting Health Care Choice and Competition Across the United States that was issued by the Department of Health and Human Services (HHS).

The ACR is calling on the HHS to revise prior authorization policies and collaborate with legislators to reverse a decision to apply Part B spending to payment adjustments under the Merit-Based Incentive Payment System (MIPS), according to a press release.

The rheumatologist group said that these changes are crucial to promote choices and competition in the health care space.

A 2016 American Medical Association survey revealed that practices complete 37 prior authorizations per physician per week, with each taking 16 hours to process.

"The current prior authorization process leads to a waste of valuable resources that delays care and does not add value to the health care delivery system," said David Daikh, MD, PhD, president of the ACR. "We encourage HHS and all agencies involved in utilization management to follow a set of best practices that ensure utilization management programs are reasonably designed and implemented."

The ACR recently partnered with health care organizations to develop prior authorization and utilization management reform principles to guide the reform of existing programs, according to the release.

The rheumatologists also urged the HHS to reverse the Centers for Medicare and Medicaid (CMS) rule that adjusts Part B drug reimbursement based on MIPS performance, according to the statement. These drug costs are not controlled by the prescribing physician.

"This dangerous policy penalizes the doctors who administer Part B therapies and will ultimately reduce patient access to treatments for diseases like arthritis and cancer, particularly in rural and underserved areas of the United States," Dr Daikh said. "This is in direct conflict with the administration's goal of promoting patient choice."

In January 2018, the ACR and more than 100 health care organizations sent letters to Congress asking to reverse the CMS policy because it will cause patient access issues, according to the release.

The ACR also urged CMS to implement pharmacy benefit manager regulation, including policies that increase drug cost transparency. It argues that the HHS should standardize rebate programs, including definitions for what is considered a rebate, discount, fee, and amount received from a manufacturer, according to the ACR.

Additionally, the organization supports the use of unique J-codes assigned to each biosimilar to ensure that physicians can track efficacy and ensure the drugs are not identified based on cost, according to the release.

"We appreciate HHS creating this opportunity to provide feedback on reforms that could result in a better, more efficient health care system," Dr Daikh said. "Laws, policies and regulations should allow providers to focus on medical decision-making without creating additional burdens that restrict patient access and limit choice."

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