• In The Trenches

    Is This the Year We Reform Prior Authorization?

    June 20, 2024

    By David Tully
    Vice President, AAFP Government Relations

    The Academy’s longtime push to reform prior authorization — which scored a significant win earlier this year with new rulemaking — is taking fresh aim at a familiar target that just got easier to hit.

    I’m talking about the Improving Seniors’ Timely Access to Care Act, just reintroduced in Congress by a bipartisan flurry of co-sponsors. It would cement CMS’ fixes to prior authorization in Medicare Advantage plans, which ensure care for some 30 million older U.S. adults, and pave the way for broader administrative simplification in other plans. If the bill’s name sounds familiar, there’s a good reason: The AAFP and numerous other health care stakeholders championed its previous incarnations. In 2022, a version even passed the House — only to be hobbled by a Congressional Budget Office estimate that implementation would cost $16 billion.

    Now, however, with CMS’ new rule prompting the CBO to radically lower that cost estimate, the 2024 Seniors’ Timely Access to Care Act has undeniable momentum. The bill would

    • establish an electronic prior authorization process,
    • require HHS to establish a process for “real-time decisions” for items and services that are routinely approved,
    • require Medicare Advantage plans to report to CMS on the use of prior authorization and the rate of approvals or denials, and
    • encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

    For more about what this means, what dramatically lowered the bill’s expected implementation cost and what we expect to happen next, I encourage you to listen to the latest episode of the AAFP’s Fighting for Family Medicine podcast series. I cover those and related topics with Peggy Tighe of the Regulatory Relief Coalition, an important Academy ally.

    Spoiler alert, though: She says the more AAFP members advocate with us to pass this bill, the better. I agree, so I encourage you to localize this issue for your representatives and senators by communicating with them about your practice and your patients, via the AAFP’s Speak Out tool. Members can click here to contact your members of Congress directly in support of the bill.

    As Peggy says during the podcast, “This issue is something you guys know cold. You know it because you face it every day with your patients. You face it every day with the insurance company hassles that you've been going through. You know how to talk about this. You don't have to have special intelligence or political insight to figure out how to talk about this. It's what you live with.”

    Our quest to reduce Medicare Advantage’s administrative burdens is also visible in a May 23 letter responding to a request for information. We called on the agency to

    • require all Medicare Advantage plans to participate in a single data collection process, which would allow family physicians to report data once rather than being forced to update information for each in-network MA plan for which they are in-network;

    • expand prior authorization transparency and reporting requirements to prescription drug coverage and Part D plan sponsors; and

    • improve payment and incentive transparency to ensure real investment in high-quality primary care.

    Congressional Testimony on Noncompete Ban

    Speaking of the Fighting for Family Medicine podcast series, if you haven’t listened yet to my conversation last month with AAFP EVP and CEO Shawn Martin about the Federal Trade Commission’s noncompete ban, catch up here (and bookmark the AAFP’s member resource page on noncompete rules in physician contracts).

    The FTC’s final rule banning noncompete agreements — a labor practice that impedes patient access to care, limits physicians’ freedom to choose their employer and practice location and contributes to physician burnout — is a big win for our workforce advocacy. But high-profile lawsuits quickly emerged, and the rule, slated to go into effect in September, is under threat.

    Addressing that legal jeopardy and the very much related problem of health care consolidation, AAFP member and Mississippi family physician Jennifer Gholson, M.D., FAAFP, testified May 23 before the Ways and Means Health Subcommittee. She told lawmakers that many family physicians across the country have been forced into a false choice of selling their practice or shutting it down to avoid economic ruin. Her testimony encouraged Congress to

    • improve Medicare reimbursement for primary care and provide prospective, sustainable revenue streams to allow physicians to tailor their practices to their patients’ needs;
    • address misaligned incentives such as site-of-service payment differentials that encourage consolidation; and
    • minimize the administrative burdens burying independent primary care practices are.

    Noncompete agreements often result from just this kind of consolidation and are increasingly restrictive.

    “As the physician landscape shifts more toward employment, noncompete agreements in health care can disrupt patient access to physicians, deter advocacy for patient safety, limit physicians’ ability to choose their employer, stifle competition and contribute to an increasingly concentrated health care market,” Gholson said in her written testimony.

    The rule and the coming legal conflicts around it are of substantial importance to family physicians. As we told the FTC last year when the rule was proposed, more than 90% of physician agreements reviewed by the physician search firm Merritt Hawkins included noncompete agreements, while about 70% of the Academy’s members are employed — half by a hospital system or a large group. 

    As with the Seniors’ Timely Access to Care Act, though, there is conspicuous support for our aims and cause for Congress to pay attention. The FTC counted more than 26,000 comments on the proposed rule and said 25,000 supported the noncompete ban. The agency has said its ban will save up to $194 billion in health care costs and that, across the employment spectrum and beyond health care, it will drive 2.7% annual new-business growth and higher worker pay.

    Noting the lawsuits already filed to challenge the FTC’s constitutional and statutory authority to issue its rule, Gholson and the Academy called on Congress in that May 23 testimony to “pass legislation that ensures and clarifies the FTC’s jurisdiction to enforce any prohibition on anticompetitive noncompete clauses across the health care industry, including nonprofit health care organizations.”

    Such jurisdictional clarification, we said, is crucial to making sure that nonprofit health systems are not exempt from enforcement, resulting in unfair competitive advantages over independent medical practices looking to recruit and retain physicians.

    There’s good precedent for this clarity. In 2020, Congress passed the Competitive Health Insurance Reform Act, which became law in 2021. In addition to limiting the antitrust exceptions available to health insurers under the McCarran-Ferguson Act, it also specified the FTC’s jurisdiction over all health insurers, including nonprofit insurers.

    “We urge Congress to make a similar clarification in future legislation to level the playing field across health care organizations and enforce antitrust laws evenly,” our testimony said.

    As Shawn Martin says on the podcast, “Simply put, we believe that patients should have access to their physicians, and physicians should be able to freely practice in their communities.”

    Last Call for PPI Survey

    As I’ve mentioned in this space before, some of you may have received an invitation to participate in the Physician Practice Information Survey. The deadline for completing this important poll has been extended to July 31. If you’ve received the survey but haven’t yet answered, please consider making the time; if you’ve already done it, thank you.

    Why is it important? Simply put, it’s a way that you can help improve physician payment.

    Run by the AMA, in tandem with the consulting firm Mathematica, and endorsed by more than 170 medical societies and other health care associations, the survey collects data on practice costs, a key element of physician payment. It’s been more than 15 years since the last such survey, making this new effort vital in the AAFP’s push for accurate payment.

    If you’re rechecking your email account, look for ppisurvey@mathematica-mpr.com as the sender; you will also have received a priority mail packet from Mathematica with a link to the survey and supporting information. 


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.