Health Policy Report – September 26, 2022

House Unanimously Passes Prior Authorization Reform Bill

On September 14, the U.S. House of Representatives unanimously passed the Improving Seniors’ Timely Access to Care Act, which is intended to place important guardrails around the prior authorization process under Medicare Advantage (MA).

If passed by the Senate and signed into law, the bill would help prevent disruptions to care, reduce administrative burdens on healthcare providers, and streamline decision making by requiring MA plans to use electronic prior authorization platforms. The legislation would also compel MA plans to annually share a list of the items and services it subjects to prior authorization, establish a process for “real-time decisions” for items and services that are routinely approved, and require MA plans to implement standards designed to protect beneficiaries’ access to care. 

“Seniors and their families should be focused on getting the care they need, not faxing forms multiple times for procedures that are routinely approved. This takes away valuable time from providers who on average spend 13 hours a week on administrative paperwork related to prior authorization,” Reps. Suzan DelBene (D-WA), Ami Bera (D-CA), Larry Bucshon (R-IN) and Mike Kelly (R-PA) said in a joint news release.

The Improving Seniors’ Timely Access to Care Act is a strong bipartisan bill. Prior to its unanimous passage in the House, it earned the support of over 320 co-sponsors from both sides of the aisle. It was also supported by over 500 advocacy groups, underscoring the bill’s popularity and importance to the country’s healthcare system. 

Prior authorization is increasingly frustrating providers and disrupting patients’ access to medically necessary care. According to a 2022 report by the Department of Health and Human Services (HHS) Office of Inspector General (OIG), 13% of prior authorization requests MA plans denied would have been covered by fee-for-service Medicare. The American Medical Association’s (AMA) 2021 AMA prior authorization (PA) physician survey found that 93% of physicians say prior authorization leads to delays in patient care. Over one-third (34%) say prior authorization has led to a serious adverse event, including hospitalization, disability, or death for a patient in their care. 

To read the text of the Improving Seniors’ Timely Access to Care Act, CLICK HERE.

To read Rep. DelBene’s press release about the passage of the bill, CLICK HERE.

To see the list of over 500 organizations who support the bill, CLICK HERE.

To read the OIG report, CLICK HERE.

To read the AMA’s physician survey on prior authorization, CLICK HERE.

Reps. Bera and Bucshon Introduce Bipartisan Bill to Block Physician Cuts 

On September 14, Representatives Larry Bucshon, M.D. (R-IN-8) and Ami Bera, M.D, (D-CA-7) introduced a bipartisan bill to prevent serious Medicare cuts to physician payments from going into effect. If enacted into law, the Supporting Medicare Providers Act of 2022 (H.R. 8800) would avert the 4.42% cut to the physician payments conversion factor expected to begin on January 1, 2023 for one year. By increasing the conversion factor that the Centers for Medicare & Medicaid Services (CMS) uses to calculate physicians’ payments by 4.42%, the legislation would provide relief to America’s doctors and provide stability to the healthcare system. 

Amid high inflation, the financial impact of the COVID-19 pandemic, and concerns about provider stability, the cuts were included Medicare’s 2023 Physician Fee Schedule proposed rule because of budget neutrality rules. On top of the conversion factor cut of 4.42%, the final rule also includes a 4% Pay-As-You-Go (PAYGO) cut that requires increases in mandatory spending like Medicare to be offset to reductions elsewhere. Representative Bera and Bucshon’s bill would only address the conversion factor cuts, not the PAYGO cuts. Facing similar conversion factor cuts in the past, Representatives Bera and Bucshon have previously partnered to advance successful legislation that forestalled certain Medicare cuts and extended increases in payments for physicians’ services under Medicare.

Stakeholder groups including the American Medical Association, American College of Surgeons, American College of Physicians, and the American Academy of Family Physicians have all publicly applauded lawmakers for introducing H.R. 8800. Physician groups also stressed the need for permanent reform. 

Additionally, Representatives Bucshon and Bera released a request for information (RFI) about the Medicare payment system along with Representatives Michael Burgess, M.D. (R-TX), Kim Schrier, M.D. (D-WA), Brad Wenstrup, D.P.M. (R-OH). Earl Blumenauer (D-OR), Mariannette Miller-Meeks, M.D. (R-IA), and Bradley Schneider (D-IL). The bipartisan group of lawmakers asked stakeholders—including physicians, economists, advocacy organizations, and health finance experts—to submit feedback on how Congress can help stabilize the Medicare payment system and support the transition to value-based care. 

To read Representative Bera’s press release on the bill, CLICK HERE.

To read the text of the bill, CLICK HERE.

To read Representative Bucshon’s release about the physician payment request for information, CLICK HERE.

To read the text of the RFI, CLICK HERE.

Nearly 400 Organizations Urge Lawmakers to Extend Telehealth Flexibilities

A group of 375 organizations, including telehealth providers, health systems, physician groups, and technology companies, sent a joint letter to U.S. Senate leadership on September 13 urging lawmakers to pass legislation extending COVID-19 telehealth flexibilities for another two years. Among the groups that signed onto the letter were Ascension, the Cleveland Clinic, the American Medical Association, the Association for Clinical Oncology, Amazon, Google, and Walmart.

Specifically, the organizations urged the Senate to “pass a two-year extension of the telehealth policies, while continuing to push for a permanent extension, that includes provisions to lift provider and patient location limitations, remove in-person requirements for telemental health, ensure continued access to clinically appropriate controlled substances without in-person requirements, and increase access to telehealth services in the commercial market.” 

The House already passed a two-year extension of telehealth flexibilities through the Advancing Telehealth Beyond COVID-19 Act (H.R. 4040) with bipartisan support of 416-12, yet the Senate has yet to take up the bill. 

Without action from Congress, flexible telehealth policies that led to very high levels of utilization early in the pandemic are set to expire 151 days after the end of the declared COVID-19 public health emergency. In the first year of the COVID-19 public health emergency, Medicare beneficiaries used 88 times more telehealth services than in the year prior, according to a recent report from the Department of Health and Human Services (HHS) Office of Inspector General (OIG). Though telehealth utilization has dropped from this peak, sustained demand remains among consumers. In addition to opening access to underserved communities, the letter also notes that telehealth has helped to address the crisis-level workforce shortage across healthcare. 

To read the full letter, CLICK HERE. 

To read more about the issue, CLICK HERE. 

To read the OIG report on telehealth utilization, CLICK HERE.

Senate Republicans Express Concerns About Drug Pricing Program in Letter to HHS

In a recent letter to Department of Health and Human Services (HHS) Secretary Xavier Becerra and Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, Senate Republicans expressed concerns about the recently passed permanent government price-setting program for prescription drugs. The Senators urged HHS and CMS to weigh the direct and indirect impacts on patients’ access to care, research and development (R&D), and domestic manufacturing.

Following a Congressional Budget Office (CBO) analysis, the Senators expressed concerns that the “government price controls” enshrined in the reconciliation package that was signed into law earlier this year could increase launch prices for new medications, lead to fewer new drug approvals, and cause manufacturers to stop participating in the Medicare and Medicaid programs altogether. Ultimately, the lawmakers worry this would limit access to critical therapies for vulnerable Americans. Additionally, the letter raised concerns from some independent analyses projecting significant domestic job losses and billions of dollars in forgone research and development dollars, harming the United States’ innovation ecosystem. 

The Senators requested further information from HHS to clarify several pieces of the program implementation by October 28, 2022, including consultation with patient advocates, caregivers, health care providers, researchers, and small businesses; quality-adjusted life years and other discriminatory metrics; methodology for determining prices; bureaucratic expansion, and monitoring effects. 

To read the full letter, CLICK HERE. 

Patients’ Out-of-Pocket-Costs for Cancer Care are Rising

On September 13, the Journal of the National Cancer Institute published a new study that found out-of-pocket costs for privately insured, nonelderly cancer patients have been growing due to the rising cost of oncological care and increased cost sharing burdens. The study, “Costs Around the First Year of Diagnosis for 4 Common Cancers Among the Privately Insured,” was carried out by researchers at the American Cancer Society (ACS) and The University of Texas MD Anderson Cancer Center. 

Examining large cohorts of breast, colorectal, lung, and prostate cancer patients diagnosed between 2009 and 2016, the researchers calculated the cost of treatment, including out-of-pocket costs expected of patients. The results show that out-of-pocket costs rose more than 15% for all cancers. The researchers estimated the average out-of-pocket costs to be more than $6,000 for breast, colorectal, and lung cancer patients and $4,500 for patients with prostate cancer in 2016. 

Overall, the study found total average costs per patient increased from $109,544 to $140,732 for breast (29%), $151,751 to $168,730 for lung (11%) or $53,300 to $55,497 for prostate (4%) cancer, while the modest increase in the cost of treating colorectal cancer (1%, $136,652 to $137,663) was not statistically significant.

In a press release announcing the findings, Lisa Lacasse, president of the American Cancer Society Cancer Action Network (ACS CAN), ACS’s advocacy affiliate, urged Congress to help reduce the financial burden on the country’s cancer patients. “Unfortunately, as these data show, cancer patients are increasingly facing a dual diagnosis of cancer and cancer-related financial toxicity. High-deductible health plans along with the proliferation of inadequate short-term plans often leave patients responsible for thousands of dollars out of pocket. These costs can then compound as many patients have to reduce their work hours or some even lose their jobs due to treatment-related side effects. We need Congress to work together to find solutions that help all cancer patients afford their care,” Lacasse said. 

To read the study, CLICK HERE.

To read a press release from the American Cancer Society on the study, CLICK HERE.

New Study Shows Cancer Rate in Adults Below Age 50 Has Drastically Increased

A new study published in Nature Reviews Clinical Oncology (NRCO) has found that early onset cancers, (cancers discovered in adults younger than 50 years old) have increased in the United States and across the globe over the last few decades. The researchers found that breast, colon, esophagus, kidney, liver, and pancreas cancer rates, among others, have “drastically” risen in younger populations since the 1990s. Individuals born after 1990 are more likely to develop cancer before the age of 50 than people born in earlier decades, suggesting that young people today will be more heavily burdened by cancer.

The NRCO report suggests that the increased incidence of early-onset cancer is partly due to an exposure to risk factors at an early age. Early life exposures such as people’s diet, weight, lifestyle, environmental exposure, and microbiome may significantly factor into what is contributing to increased rates of early-onset cancer, although specific effects of individual exposures remain unknown. The report also suggests that even in-utero exposures and alcohol consumption may have a long-lasting impact, with research suggesting anywhere between 5% to 10% of all cancers worldwide are due to alcohol use. 

The serious rise in early onset-cancers is also partially attributable to the normalization of early cancer screenings for younger people. By helping identify early-onset cancers that may have otherwise been missed, Improved access to screening, especially at an earlier age, helps explain the trend the researchers found. 

In the years ahead, the researchers argue that raising awareness of early-onset cancers and improving the early-life environment should be vital policy goals in order to help prevent cancer.

To read the full Nature Reviews Clinical Oncology study, CLICK HERE.
To read a summary of the findings, CLICK HERE and HERE.