May 7, 2019
The Honorable Raul Ruiz
2342 Rayburn House Office Building
Washington, DC 20515
The Honorable Brad Wenstrup
2419 Rayburn House Office Building
Washington, DC 20515
Dear Representatives Ruiz and Wenstrup:
On behalf of the Medical Group Management Association (MGMA), I want to thank you for the introduction of the Safe Step Act of 2019 (H.R. 2279). MGMA strongly supports this legislation and appreciates your leadership in this effort to improve patient care and reduce administrative burdens associated with prior authorization for the nation’s physician practices.
MGMA is the premier association for professionals who lead medical practices. Since 1926, through data, people, insights, and advocacy, MGMA empowers medical group practices to innovate and create meaningful change in healthcare. With a membership of more than 45,000 medical practice administrators, executives, and leaders, MGMA represents more than 12,500 organizations of all sizes, types, structures and specialties that deliver almost half of the healthcare in the United States.
For more than a decade, MGMA has been advocating for a reduction in the volume of health plan prior authorization requirements. Of the many onerous administrative processes required in today’s healthcare environment, prior authorization is perhaps the most frustrating for physician practices and patients alike. Despite recent efforts to advance electronic prior authorization, practices still contend with manual prior authorization processes conducted through phone, fax, health plan web portal, or even the US postal service. Adding to this burden, MGMA’s research indicates that health plans are actually increasing their prior authorization requirements.
Most concerning, patients can be forced to interrupt ongoing treatment due to health plan utilization management coverage restrictions which can result in a negative impact to their care and health. Many health plans employ step therapy protocols, under which patients are required to first try and then fail certain therapies prior to qualifying for coverage of other treatments. These programs can be particularly problematic for patients—such as those purchasing coverage on the individual marketplace—who change health insurance on an annual basis. Patients who move from one health plan to another are often required to disrupt their current treatment to retry previously failed therapeutic regimens to meet step therapy requirements for the new plan. Forcing patients to abandon effective treatment and repeat a therapy that has already been proven ineffective under other plans’ step therapy protocols can significantly delay care and may result in negative health outcomes.
Recently, MGMA, the American Hospital Association, the American Medical Association, and the American Pharmacists Association joined with America’s Health Insurance Plans and the Blue Cross Blue Shield Association to release the Consensus Statement on Improving the Prior Authorization Process
. This statement included a commitment to the continuity of patient care and recognition that continuity of patient care is vitally important for patients undergoing an active course of treatment when there is a formulary or treatment coverage. Critically, the coalition agreed to encourage “sufficient protections for continuity of care during a transition period for patients undergoing an active course of treatment when there is a formulary or treatment coverage change or change of health plan that may disrupt their current course of treatment” and “support continuity of care for medical services and prescription medications for patients on appropriate, chronic, stable therapy through minimizing repetitive prior authorization requirements.” Despite this commitment in 2018 from the two largest organizations representing health plans, little has changed in reducing prior authorization requirements for step therapy.
This lack of movement from health plans is precisely why the introduction of the Safe Step Act of 2019 is so welcomed and passage of the bill so vital. Again, we thank you for your leadership on this critical issue and MGMA stands ready to work with you and your congressional colleagues to ensure swift passage of this important legislation. Should you have any questions, please contact Claire Mansbach at firstname.lastname@example.org or 202-293-3450.
Anders Gilberg Senior Vice President, Government Affairs
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