News from the AGA

AGA seeks regulatory relief for GIs


A top priority for AGA this year is to call on the Centers for Medicare & Medicaid Services (CMS), other payors, and Congress to alleviate some of the regulatory burden that currently falls on physicians. Reevaluating prior authorization, step therapy, and Stark reform would allow physicians to devote more time and resources to provide high-quality care. A more comprehensive breakdown of the following key areas is available along with other top issues.

Prior authorization

• AGA urges payors to standardize prior authorization requirements and criteria and make them transparent and easily accessible. The services subject to prior authorization vary by payor, including CMS, as well as by plan type within a given payor. Physicians and physician practices are forced to comply with an increasing and unmanageable number of prior authorization requirements.

• AGA urges payors, including CMS, to develop and implement processes that allow for true “peer-to-peer” dialogues. Gastroenterologists seeking prior authorization for prescription drug or biologic therapy on behalf of a patient should be routed to a physician specialist in the same or similar discipline with expertise in the given condition to discuss the request.

Step therapy

• Step therapy, also known as “fail first,” occurs when an insurer requires patients to try and fail one or more lower-cost prescription drug or biologic therapies before covering the therapy originally prescribed by their health care provider.

• AGA urges insurers to reduce the burden of step therapy on physicians and physician practice. AGA supports The Restoring the Patient’s Voice Act (H.R. 2077), legislation introduced by Rep. Brad Wenstrup, R-Ohio, and Rep. Raul Ruiz, D-Calif., both physicians, that would provide a clear and timely appeals process when a patient has been subjected to step therapy.

Stark reform

• Stark self-referral laws prohibit physicians from referring patients to an entity in which they have a financial interest, which limits their ability to participate in many advanced alternative payment models (APMs). These prohibitions stifle care delivery innovation by inhibiting practices from incentivizing their physicians to deliver patient care more efficiently, because the practices cannot use resources from designated health services in rewarding or penalizing adherence to new clinical care pathways.

• AGA supports S. 2051/H.R. 4206, the Medicare Care Coordination Improvement Act, which would provide CMS with the regulatory authority to create exceptions under the Stark law for APMs and to remove barriers in the current law to the development and operation of such arrangements.

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