AAFP Advises CMS on Prior Authorizations, Opioid Epidemic

March 07, 2018 11:02 am News Staff

In a recent letter to CMS, the AAFP discussed two topics of great importance to family physicians and their patients who will be enrolled in Medicare Advantage and Medicare Part D plans in 2019.

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Specifically, the AAFP offered recommendations on how to improve prior authorization processes and suggested ways to ensure that family physicians are part of the opioid epidemic solution.

The Feb. 27 letter(4 page PDF) to Demetrios Kouzoukas, CMS principal deputy administrator, was signed by AAFP Board Chair John Meigs, M.D., of Centreville, Ala.

The AAFP was responding to a document the agency issued on Feb. 1,(www.cms.gov) titled "Part II of the 2019 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies and Draft Call Letter," that covers policy and technical changes to specific CMS programs.

The response complements a Jan. 16 letter(12 page PDF) to CMS Administrator Seema Verma, M.P.H., that covered other areas of concern.

Story Highlights
  • The AAFP recently gave CMS concrete feedback on how to address issues with Medicare Advantage and Medicare Part D programs.
  • The AAFP's comment letter focused on improving the prior authorization process and improving drug utilization review controls.
  • The letter also pointed out that family physicians are well suited to be part of the opioid epidemic solution.  

Prior Authorization Processes

The AAFP lauded CMS for language in the Part II draft that reminds Medicare Advantage plans about the need for transparency and the importance of giving adequate notice of coverage restrictions for both physicians and their patients.

The AAFP's letter called out the lack of standardization among public and private payers, and referred to the current regulatory framework as "daunting and often demoralizing."

Family physicians often deal with 10 or more payers, noted the AAFP. "Physicians spend needless hours reviewing documents and literally checking boxes to meet the requirements of each health insurance plan," time that could be better spent on direct patient care.

The Academy urged CMS to act more boldly by requiring Medicare Advantage and Part D plans to follow specific principles of prior authorization. Specifically, prior authorizations

  • must be justified in terms of financial recovery, cost of administration, workflow burden and lack of other methods of utilization control;
  • must include transparent rules and criteria, reasons for denial of a service or medication, and alternative medication choices; and
  • should be discarded when physicians have aligned financial incentives, such as shared savings, and have shown successful stewardship.

Furthermore, CMS should seek to eliminate prior authorizations altogether for durable medical equipment, supplies and generic drugs.

The AAFP also asked CMS to take "transitional steps" to improve the prior authorization process by, for instance,

  • curbing the number of products and services that require prior authorization;
  • requiring a standardized form and process for prior authorization among all payers;
  • mandating payment to physicians for completing prior authorizations beyond a specific number and for those not resolved within a certain timeframe; and
  • prohibiting repeated prior authorization requests for medication management that has been proven to be effective for patients with chronic diseases, as well as for standard and inexpensive drugs.

Improving Drug Utilization Review Controls

The AAFP acknowledged and agreed with CMS' concern about the very real risks of addiction, overdose and death associated with opioid medications and suggested some solutions.

For instance, the AAFP noted that patient management and dependence therapy requires treatment based on patient-centered and compassionate care. Although these are "attributes that family physicians bring to their relationships with patients," the current payment and regulatory framework has reduced physicians' one-on-one time with patients.

The Academy called for incentives that would encourage patients to see their primary care physicians to access screening, brief intervention and referral to treatment.

"Family physicians have a unique opportunity to be part of the opioid solution," the AAFP contended. "Effective pain management should be coordinated by a primary care physician who best knows the patient" and who can integrate this treatment into "continuous, comprehensive whole-patient care."

The AAFP suggested that payment incentives could be used to remove or reduce copays for screening and treatment for opioid use disorder and substance use disorder and to support coprescribing of naloxone.(207 KB PDF)

The Academy also stated that it unequivocally "opposes limiting patient access to any physician-prescribed pharmaceutical without cause, as well as as any actions that limit physicians' ability to prescribe these products based on the physician's medical specialty."

Lastly, the AAFP expressed its support of effective state prescription drug monitoring programs (PDMPs) and noted that it encourages physicians to "use their state PDMPs before prescribing any potentially abused pharmaceutical product."

However, the Academy added, the success of PDMPs "depends on state reporting systems that are accessible, timely, interoperable and comprehensive."

The letter outlined the AAFP's support for a national PDMP driven by an interoperable and secure national database.

Until the country embraces a national PDMP, the AAFP and its chapters "will continue working to encourage the use of state PDMPs and bring localized and state-specific education to our members and their care teams."

The Academy's letter concluded by addressing the "overwhelming impact " of the current opioid crisis on the health and well-being of Americans and calling out the low payment provided to primary care physicians for patient visits billed with a mental health diagnosis CPT code.

"Many managed care plans do not pay family physicians for the provision of mental and behavioral health care, even though family physicians are frequently in the position to diagnose, treat and provide the needed care," said the AAFP.

The letter asked that CMS and Medicare Advantage plans rectify that situation and "adequately pay for prevention programs and counseling/outreach programs to support the children and families" impacted by opioid and substance use disorders.

Related AAFP News Coverage
AAFP Steers CMS on Proposed Changes to Medicare Advantage
(1/17/2018)

New AAFP Policy Takes Aim at Prior Authorizations
(5/26/2017)

Medical Organization Coalition Calls for Prior Authorization Reform
AAFP Also Drafts Policy on Requirements

(1/26/2017)

More From AAFP
Chronic Pain Management Toolkit

Position Paper: Mental Health Care Services by Family Physicians