By Mary Beth Donahue and Mark Mantei / For the Herald
Maybe this scenario sounds familiar: You or a loved one go to pick up a prescription or to access a health care service, only to learn that it requires a prior authorization.
Prior authorization — a process by which a health plan confirms with the health provider that a particular treatment or service is the best option for an individual patient — has a legitimate function in our health care system; working to reduce waste and low-value care and to protect patients from duplicative services or unexpected bills.
While the impact on consumers is often minimal, (a recent poll found that only 6 percent of respondents “often” encountered a prior authorization) for the minority of beneficiaries who have experienced a prior authorization, the process is ripe for change.
Prior authorization can be found just about anywhere, whether you are insured through a private company or the government, but a diverse slate of lawmakers, led by U.S. Rep. Suzan DelBene, D-Wash., are taking action to specifically modernize this process in Medicare Advantage, the Medicare option where more than 560,000 Washington seniors and individuals with disabilities choose to receive their coverage today.
At a time of increasing polarization and gridlock, DelBene has done the unthinkable: amassing more than 290 bipartisan cosponsors — more than two-thirds of the U.S. House of Representatives — on a substantive bill to build upon the work health plans are already doing to streamline the way prior authorization works for beneficiaries. Her bill, the Improving Seniors’ Timely Access to Care Act (HR 3173), offers lawmakers their single best opportunity to deliver a health care win for their constituents this year.
DelBene’s legislation has three main components: First, it would bring prior authorization into the 21st century by requiring the use of electronic prior authorization; no more paper forms. Second, it would direct the government to establish a process for real-time prior authorization decisions for items and services that are routinely approved. And third, it would inject added transparency into the prior authorization process by requiring health plans to report on the percentage of prior authorization requests that are approved and the average response time.
The bill also provides mechanisms to make sure these policies work as intended, including requiring the Department of Health and Human Services to submit a report to Congress evaluating its implementation of the bill.
With studies already showing that Medicare Advantage delivers nearly $2,000 in annual savings to consumers and lower per-beneficiary spending for taxpayers, DelBene’s thoughtful legislation offers another way that Medicare Advantage can continue to raise the bar in the delivery of affordable, accessible coverage and care.
That’s why our organizations — Better Medicare Alliance, a community of health care organizations and grassroots seniors that includes over 7,000 Washingtonians, and Vancouver Clinic, an independent, 450 clinician multi-specialty group practice serving some of our most vulnerable residents in southwest Washington and Oregon — are supporting the legislation.
Perhaps it’s also why other leaders from across the state, including Reps. Rick Larsen, D; Jaime Herrera Beutler, R; Derek Kilmer, D; Kim Schrier, D; Adam Smith, D; and Marilyn Strickland, D, are rallying around this commonsense legislation as cosponsors. We hope the rest of their colleagues in the Washington delegation will join them.
In our narrowly divided Congress — one that often subsists on partisan messaging bills that make for better headlines than laws —DelBene’s legislative feat stands out. The Improving Seniors’ Timely Access to Care Act commands our respect and deserves Congress’ swift passage.
Mary Beth Donahue is the president and CEO of the Better Medicare Alliance and former chief of staff at the U.S. Department of Health and Human Services during the Clinton administration. Mark Mantei is CEO of Vancouver Clinic, the largest independent, multispecialty group practice in the Pacific Northwest.