Process needs to be less burdensome, Verma says
This article was first published on Thursday, August 15, 2019 in MedPage Today.
By Joyce Frieden, News Editor, MedPage Today
WASHINGTON -- Fixing prior authorization is still a priority for the Trump administration, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said Thursday.
Prior authorization and utilization management "have been shown to be a very effective method of assuring appropriate care, and [to assure] that you don't have inappropriate use of the program ... In the Medicare program, you see in some areas we have large profit margins and at the same time we have high improper payments," Verma said at a briefing with reporters. "So that kind of screams [that] there needs to be more oversight of utilization and that's where you use the prior authorization program. So the way that I'm looking at it is, we're going to have to have prior authorization. We're not going to do away with those types of programs."
"That being said, we've got to make them work in a way that doesn't interfere in the practice of medicine [so] that there are not delays, that patients can get access to the services they need in a timely manner," she continued. "So I'm looking at how do we make the process work to be less burdensome but also achieve the outcomes that it's intended to?"
Verma also discussed several other issues at the briefing, including:
The "public charge" proposed rule. Under a proposal from the Department of Homeland Security (DHS), legal U.S. residents who are applying for a green card will have it counted against them if they have used public programs such as Medicaid or food stamps. However, the rule has been modified from its original form, Verma told MedPage Today. "From their proposal to the finalization of the rule, [DHS] did make some changes." For example, "they did make exemptions for pregnant women, for children, for low-income seniors."
"At this point, it's very speculative to say what will happen and what won't happen," she added. "My understanding of the rule is this is one of many factors they're looking at when making decisions about somebody's legal status or about their path to citizenship, so I think right now it's premature to speculate what the impact would be."
Practice consolidation and competition. Verma bemoaned the fact that the number of independent practices has been decreasing each year because they are being bought out by hospitals. "What I worry about going forward is making sure that we always have an environment that creates competition ... When doctors are bought out by a particular hospital, you see the referrals to that hospital go up ... We're concerned about what that does for pricing in these markets."
That's one reason CMS is advancing "site-neutral" payment policies in Medicare, she continued. "I understand that there are differences in pricing between a hospital and maybe an outpatient center or a doctor's office, because [hospitals] do have more safety requirements." However, that argument doesn't really apply to a simple outpatient visit because there aren't any additional safety requirements for those, and it's not fair to patients who have to pay higher copays just because they happened to be at a hospital outpatient center rather than a physician's office, she said. "That's why we made these changes; it's about competition, but it's also about the patient."
The "two-midnight" rule. Under this rule, if a patient stays at a hospital through two midnights, Medicare generally will consider the patient as an inpatient and reimburse for the patient's care under the Medicare Part A program. Patients who stay for less than that amount of time are considered to be "observation" patients and will be covered as outpatients under Medicare Part B.
Verma said this rule was an example of rules that CMS would like to change but can't. "We have looked at this issue many times," she said. "[This is] an example of government policies that don't work, that don't make sense, that create problems ... I don't think that we have the authority to make the type of change that we would like to make." She did not specify what that change would be.
"We wrote a letter to [leaders on Capitol Hill] and we said, 'These are the issues [including this rule] that we don't have the authority [to change] but we wanted you to know' that there are problems with them," she said. "And that was something that we've already brought to their attention."
Medicare for All. Verma was asked what she thought of Democratic presidential candidate Kamala Harris's version of a Medicare for All healthcare plan, which builds on the Medicare Advantage program. "I like Medicare Advantage and I'm supportive of Medicare Advantage because it creates competition and there's choice, and that competition is around price and quality and people have the opportunity to pick what's going to work best for them," she said.
However, Medicare Advantage -- which contracts with private health insurance providers to provide services to Medicare patients -- is still a government-run program and still has all the problems that come with that, she continued. "We just added telehealth and supplemental benefits, and it took years to get them," she said. "So that's the example of, yes, these are private health plans, but they are governed by government policies and it kind of limits their ability to innovate."
“How do we make the process work to be less burdensome but also achieve the outcomes that it's intended to?”
CMS Administrator Seema Verma
Prior authorization and utilization management are a 'very effective method of assuring appropriate care' says CMS Administrator Seema Verma.
However, she added, 'we've got to make them work in a way that doesn't interfere in the practice of medicine.'
Verma bemoaned the number of independent practices that are being bought out by hospitals.
Verma says the "Two-midnight Rule" was an example of rules that CMS would like to change but can't.