Prior authorizations and MedPAC recommendations: MGMA’s view

Prior authorizations and Medicare reimbursements are some of the most consistently cited sources of issues at primary care practices.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), joined us in April to discuss his organization’s lobbying efforts in Washington.

The following interview has been edited for length and clarity.

Medical World News: Your organization gave comments to the federal government on the state of prior authorization in America recently.

Anders Gilberg: Prior authorization is just always a constant thorn in the side of our medical practice members. We did a survey a month ago, in which 80% of our members said that over the last 12 months prior authorization requirements had increased. And we're seeing that every year just a continuing increase in the burden of prior authorization on medical practices. And when we do our regulatory relief, or regulatory burden survey every year, it always rises to the top in terms of the largest burden that our members face.

The request for information was a little bit more technical, but it was on automating, what can we do to automate prior authorization. And that's important. But the way we responded to it is that (automation) is one piece of an overall strategy that we think would be effective at reducing the burden on medical practices with prior authorization. What we don't want to do is just make it easier and have more prior authorization. Ultimately, our goal is to reduce the number of situations in which a health plan is questioning the clinical judgment of a physician and making that judgment on behalf of patients. Reducing the volume of prior authorization in this country is our number one priority. But that said, we think that the prior authorization (standards) can be very helpful. One of the things that our members often run into, is that there's not one standardized way to submit prior authorizations or to submit additional information, maybe clinical information, maybe some chart information, to the health plans, there's not one standard in this country. So, each health plan thinks they have like the best proprietary way to make it really easy. However, I'll use myself as an example, if I had 20 separate websites to log on to and then have passwords for every one of those websites, it quickly becomes burdensome. Each website may be efficient, but each one is different. I would lose track of those passwords. And it would just be a problem.

Now, medical practices are more sophisticated than I am in that regard. However, they may have contracts with 20 to 30 major health plans in their market, and if each one of those has its own electronic portal, with a password, each one's different. The way it works, you have to hire staff to go in there and learn each one of those processes. And it's just time consuming and redundant. So, ideally, what we're looking for is one standard, and one way of submitting them; like pushing a button, maybe even having it integrated with an electronic medical record and the clinical record. We could provide the information that health plans need but do so in a streamlined way that isn't just multiplied by 20, and have that staff burden.

So, overall, electronic prior authorization is something that we're looking for, and we're advocating for. As part of our letter, we gave some recommendations on how to implement the electronic version of it, but not do so in a way that just creates more prior authorization. Ultimately, what we want is those, there multiple situations in which maybe a physician who has high quality and low cost, they're already being measured on value by the health plan, we want to exempt those physicians from prior authorization. If they're in a value-based arrangement, they're already incentivized to increase quality and reduce costs. They're held accountable already. So why layer any additional type of utilization review from the health plan to just add burden on the practice?

It was a great opportunity to complement some of what we're doing with Congress. I'll mention, also, we are supporting legislation, the Improving Seniors’ Timely Access to Care Act. So, if you're interested in that Senate Bill 3081, or House Bill 3173. And we're promoting that legislation as a way to reduce the number of prior authorizations help those physicians in value-based arrangements get out from underprior authorization and focus on in this case, Medicare Advantage plans, where we see a lot of it and, and really get the ball rolling with Medicare prior authorization reform in this country. So ideally, we want to each year reduce that number that are that our members are telling us. And so, you know, it's disturbing that 80% of them said that it increased over the last year, you know, we're responding accordingly.

MWN: What is your organization’s position on the Medicare Payment Advisory Commission (MedPAC) recent recommendation on Medicare reimbursements?

AG: Yeah, so it was a bit surprising. It was disheartening and disturbing to hear Medpac make that recommendation of a zero percent update in 2023. The news literally almost came out the exact day we were getting CPI reports out of the government of, seven, eight and a half percent increases in inflation.

So, our medical practices, our members are reporting incredible problems. Recruiting staff is a big issue right now and many of our practices in this current environment have had to limit their hours or have had to close satellite locations, because they do not have the clinical staff. It's one thing if you have a doctor, but if you don't have a team of a nurse, and team around that position to actually open up a medical practice to room patients to do all the things that we all expect when we go to the doctor, then you can't provide those services in the way you need to do it. So, it's an incredible burden. And it wouldn't solve everything.

We want to make sure that our members and medical practices across the country receive equitable payment from the Medicare program. So, they don't have to limit the number of Medicare patients they see or treat. The last thing we want in this country is any kind of access problem for Medicare beneficiaries. It was concerning that MedPAC would say no 0%, we don't see any reason to update payments, even in this environment. So that that's a concern for sure.