Letter from the Chair
Robert Krug, MD President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line
Ripple Effects In a recent issue of the Journal of the American Medical Association (JAMA), a set of articles analyzed an issue that has received significant consideration from our Association and many other health care stakeholders in recent months – prior authorization. While much of the attention has been focused on the clinical and administrative burdens created by these policies, the JAMA articles were wholly focused on the impact prior authorization has on patients and caregivers. Notably, but not surprisingly, one article1 found that “the financial toll, emotional distress, and psychological effects [created by prior authorization policies] on patients can be substantial and recourse can be limited.” A second article2 called more broadly for efforts to “promote transparency, efficiency, and fairness” in prior authorization policies, such as by “requiring the cases be reviewed by someone of the same specialty who has knowledge of the condition and medication.” As chairman, I’ve made the patient perspective one of the focal points of AMRPA advocacy and communications this year. To that end, the impact of prior authorization policies on our patients – particularly in the Medicare Advantage (MA) program – is our primary focus when engaging with Congress and policymakers in 2020. I’ve been heartened to see the bipartisan backing and support from approximately 400 organizations for H.R. 3107, the Improving Seniors’ Access to Timely Care Act, and I spent time on Capitol Hill in recent months championing for revisions that could make a real-world impact on our patients. For example, while I’ve heard broad agreement that “timely” prior authorization decisions are needed, it’s critical to consider what “timely” means for potential inpatient rehabilitation patients and their caregivers as they wait for a plan decision in an acute hospital setting. I’ve watched MA beneficiaries wait one to three days – and even longer when they become ready for discharge on a weekend – for a final prior authorization determination on their claim. This timeframe is completely unworkable and unnecessary, and significantly increases the likelihood that patients are discharged to a less appropriate setting. The clinical impact on the patient – as well as the emotional toll for caretakers – presents a clear impetus for reform. This was my focus during my recent Congressional visits on behalf of AMRPA, and I urge members to emphasize these types of patient impacts in your own outreach with your elected officials. The need for patient-focused advocacy is even more important in light of a recent proposal in the FY 2021 Department of Health and Human Services (HHS) budget that would expand the use of prior authorization for inpatient rehabilitation services to the traditional fee-forservice Medicare program. Such effort would expose millions more beneficiaries to the risk of delayed or denied access to inpatient rehabilitation and other impacts described in the JAMA article. AMRPA has and will continue to highlight the patient impact of prior authorization as our association tackles this issue on multiple policy fronts, and I look forward to continued discussion both among members and with policymakers this month at our Spring Conference.
1
Changing the Game of Prior Authorization: The Patient Perspective. Martha E. Gaines, JD, LLM; Austin D. Auleta, BA; Donald M. Berwick, MD, MPP. JAMA. Published online February 3, 2020. doi:10.1001/jama.2020.0070
2
Refocusing Medication Prior Authorization on Its Intended Purpose. Jack S. Resneck Jr, MD. JAMA. Published online February 3, 2020. doi:10.1001/ jama.2019.21428
4
AMRPA Magazine / March 2020
