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Rheumatologists target prior authorization, Stark Law as barriers to competition


Onerous prior authorization rules, Stark Law, and other issues are creating barriers to health care choice and competition, the American College of Rheumatology recently told the Department of Health & Human Services.

The agency recently issued an informal request for information seeking “input from the public on the extent to which existing state and federal laws, regulations, guidance, requirements, and policies limit choice and competition across all health care markets, and the identification of actions that states or the federal government could take to support the development and operations of a health care system that provides high-quality care at affordable prices for the American people.”

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In targeting prior authorization requirements, the ACR cited a 2016 American Medical Association survey of 1,000 practicing physicians that shows a medical practice completes an average of 37 prior authorizations per week, averaging 16 hours.

“We believe this is a waste of valuable resources that results in delays in care and does not add value to health care delivery,” the ACR said in its Jan. 25 reply to the request for information. The ACR offered a series of recommendations to make the use of prior authorization by the Centers for Medicare & Medicaid Services more efficient.

Among the requested changes are:

• CMS should require all Medicare Advantage and Part D prescription drug plans to publicly disclose in a searchable electronic format to both patients and physicians all drugs and medical services that are subject to coverage restrictions (prior authorization, step therapy, formulary restrictions, quantity limits), and provide this information to vendors to be displayed in electronic health records.

• CMS should ensure that all utilization management requirements are based on accurate and up-to-date, publicly available clinical criteria and never cost alone.

• CMS should ensure that any “peer-to-peer” reviews utilize physicians from the same specialty/subspecialty as the ordering physician.

• CMS should restrict prior authorization requirements to “outlier” providers whose prescribing or ordering patterns differ significantly from their peers after adjusting for patient mix.

• CMS should not allow Part B services to be subject to prior authorization requirements because this would increase physician time spent on administrative tasks and reduce availability for patient care.

In addition, the ACR expressed concern about the consolidated pharmacy benefit managers market, noting that two PBMs cover more than 170 million Americans, and urged the HHS to “consider policies that require PBMs to be more transparent about their payment practices, including transparency around the true cost of prescription drugs.”

In the area of the Stark Law, the ACR called for the HHS to waive the prohibitions “for physicians seeking to develop and operate alternative payment models (APMs) as was provided to accountable care organizations in the Affordable Care Act. We also recommend removing the ‘volume or value’ prohibition in Stark policy so that physician practices can incentivize physicians to abide by best practices and succeed in new value-based alternative payment models.”

The ACR asked the CMS not to alter policy on assigning unique J-codes to biosimilars, as the unique codes allow for better monitoring of effectiveness and ensure adequate pharmacovigilance.

The physician organization also called for the removal of antitrust exemptions to insurance companies to give “the federal government the ability to intervene in places where insurance monopolies exist or develop.”

One request made – the removal of Part B drug payments from being adjusted by scoring in the Merit-based Incentive Payment System in the Quality Payment Program created by MACRA – was addressed in legislation passed by Congress and signed into law Feb. 9 by President Trump that provided short-term funding for the government and funding and other policy changes in the health care space, among other issues.

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