Rep. Michael Burgess: Transition to Values ​​and Quality

A recent American Medical Association survey found that physicians and staff spend more than 16 hours per week fulfilling prior authorization requirements to provide patients with the drugs, medical services, or basic procedures they need, as determined by their medical teams. The survey showed that on an annual basis, more than 800 hours are spent on pre-authorization tasks. The potential result is a delay in patient care, often by months.

Inspired by Texas law, I introduced the GOLD Card Act of 2022. This law will exempt providers who have received 90% of their requests approved in the past 12 months from Medicare Advantage recipient pre-clearance delays. In addition, the bill would allow physicians to appeal an attempt by a Medicare Advantage plan to revoke an exemption.

The concept of performance rewards is not new to healthcare. One of the core principles of value-based care is that service providers should be rewarded for the quality of care they provide. So adopting a gold card policy will allow our healthcare system to move to a card based on value and quality rather than volume.

The same AMA survey shows the negative impact of prior authorization on physicians and patients. More than a third of doctors said the delay in issuing permits has resulted in hospitalization, disability, permanent injury or even death for patients in their care. In addition, 82% of physicians said the requirements had previously led patients to refuse treatment. According to a report by the Council for Affordable Quality Health Care, in 2019, the cost of processing pre-clearances was about $528 million. These statistics show the impact on individual patients and the healthcare system as a whole.

Like cost, the efficiency that could be achieved under the GOLD Card Law is important to physicians. The Office of the Inspector General of the Department of Health and Human Services found in an April 2022 report that 13% of Medicare Advantage plan pre-approval denials in June 2019 were for benefits that would otherwise be covered by Medicare. The OIG cited the use of clinical guidelines not contained in the Medicare coverage rules as a reason for the wrongful denial. Basing the exemption on the approval rating of previously provided services allows the clinician to be more efficient and simplifies the process of developing a care plan for the patient.

Texas and West Virginia are the only states to have fully adopted a gold carding policy, and at least five other states are interested in such a law. A recent study by the Kaiser Family Foundation found that 99% of Medicare Advantage beneficiaries are in plans that require prior authorization. Given that this process affects a significant proportion of patients across the country, correcting it is a critical component of improving efficiency and further enhancing the quality and value of our healthcare system.

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