AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger is joined by Rep. Suzan DelBene (D-WA), a member of the House Ways and Means Committee and chair of the moderate New Democrat Coalition, about the “Improving Seniors’ Timely Access to Care Act,” an important piece of bipartisan legislation that would help ease prior authorization challenges physicians face in caring for their senior patients. Rep. DelBene is one of several bipartisan representatives who introduced this legislation in Congress and is working to get it passed.
Find more information on the AMA's efforts to fix prior authorization.
- Representative Suzan DelBene
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're talking about the “Improving Seniors’ Timely Access to Care Act,” an important piece of bipartisan legislation that would help ease prior authorization challenges that physicians face in caring for their senior patients. Our guest today is representative Suzan DelBene from Washington state who's a member of the House Ways and Means Committee, chair of the Moderate New Democrat Coalition and one of several bipartisan representatives who introduced this important legislation in Congress and is working to get it passed. I'm Todd Unger, AMA's chief experience officer in Chicago.
Representative DelBene, thank you so much for joining us today and for all the work that you've done on behalf of this legislation. Prior authorization has been a huge challenge for physicians and over one-third of physician respondents to a recent AMA survey revealed that prior auth led to a serious adverse event for a patient in their care. So let's just start by talking about what prompted you personally to take a leadership role on this issue at the federal level.
DelBene: Well, first of all, Todd, thanks for having me. It's great to be here and talk about this incredibly important issue. I don't have the background of a typical member of Congress. I came to the House after a long career working in technology, and one of my priorities has been to make sure that our policies have kept up with the way the world works today. And I was surprised at how far behind we are in using digital technologies as we should, and the lack of understanding there, but I've also been surprised at the challenges we face, particularly on something like prior authorization, where we are using cumbersome methods, fax machines, to exchange information and the opportunity that we have, not only to update how we use technology to make this process more speedy, but to standardize it.
I think we all have stories of family members, folks we know who have had delays in access to care because they haven't gotten approval in a timely manner. And so, this is critically important to folks across the country. I know we've heard from physicians the challenges that are in place and how hard it is to have to use different forms or reply over and over for little bits of information here and there and spend all this time on administration versus caring for patients. So I think our legislation is a straightforward fix that will make a huge difference for patients and for providers.
Unger: We'll get into details about the legislation in a moment, but broadly speaking, it addresses the way that Medicare Advantage Plans use prior authorization and focuses on streamlining and simplifying the processes associated with it. When did you and your fellow bill co-sponsors first realize that this was a problem that really needed to be addressed?
DelBene: About a year before we started working on the bill, we were hearing from providers very regularly about how cumbersome the process has become. This prompted my colleagues, Representative Mike Kelly and Dr. Ami Bera to send a letter to CMS. We asked them to address this issue and when CMS politely declined, we knew it was time for legislation. It's definitely a bipartisan story because we see this problem. We know that by working together, we can make a difference. And so there's really been a close collaboration to work on legislation and our offices have worked really well together. And frankly, the opportunity to do something in a bipartisan way is more rare these days.
We have over 290, I think, over 300 co-sponsors now, which is really unheard of, but it's because of the great collaboration that have taken place and just the clarity of the problem that we see out there in our communities. I think that gives us the opportunity to find a path forward to address this.
Unger: And it's great to hear that this is a bipartisan effort. Can you just give a little bit background, describe the working relationships that you've developed with other co-leads on this legislation and the House and Senate and how you have been able to work together to address the issue?
DelBene: Well, our staff meet regularly. We've met regularly because we are hearing the same stories from our constituents, stories from providers throughout the country. And so we've worked together to draft the legislation, to continue to build support with our colleagues on both sides of the aisle to work also with our Senate colleagues to build support so that we have not only a strong bill, but also make the case for why the bill needs to move forward.
So it's really been very collaborative and between us as members but also our staff working closely together and working with folks on our committees to continue to not only educate folks, but to really build that pathway so we can get the bill across the finish line.
Unger: And I think every physician and many patients are very familiar with the burdens of this particular process. And we've seen recently some headlines about the consequences of the current way that Medicare Advantage Plans operate, particularly some conclusions that came out of Health and Human Services Officer Inspector General Report that found that Medicare Advantage Plans were inappropriately denying medically necessary care. You talked about some of those stories before. Paint a picture for us about some of the scenarios you've seen where patients have been negatively impacted by this.
DelBene: Well, one great example is one of my relatives, their parent was scheduled to have surgery and this was right after COVID when surgery was finally opening up again. And unfortunately, they didn't get authorization in time and had to cancel that surgery, reschedule it for later because prior authorization didn't happen in a timely way. So, there's one story. There are so many stories that we've heard and if you, or your loved one are frustrated by the health care system, it's not just you, we know, it's folks across the country and so many families. And I think the Office of the Inspector General Report that you referred to really crystallized what we already knew was happening and the challenges that we faced with prior authorization. So, we need to bring it into the twenty-first century and this legislation will do that.
We also heard the story about a year ago of a major insurer denying prior authorization, or decided they needed prior authorization for every cataract surgery. Pretty much a critical, common surgery that takes place. If you put it off, you're putting your patients in a more difficult scenario too. So, we also wanted to make sure we had clear practice established, clinical practice guidelines. We know that if things are common, there's less reason they should be delayed. And one of the things we want to make sure we do in the legislation too, is gather data. So we know that things aren't delayed for no reason. We want to make sure that common clinical practice is approved quickly and having that data will really help us to show whether that's happening or not, or address ongoing issues.
Unger: It's interesting hearing you tell that story. We also spoke with our Immediate Past President Dr. Harmon who experienced the same thing with his own mother. It really kind of brings it home to see it in your practice and with your family. The foundation of this particular legislation is based on principles from a 2018 consensus statement that captured an agreement between health plans and health care professionals, including the AMA, on how the prior authorization process could be improved. And there are really five key points. One of them you related just now which is that selective application of prior authorization and regular review and adjustments, the criteria, greater transparency and communication between physicians and health plans, maintaining continuity of care, of course, and enhancing automation and efficiency, which I don't think includes fax machines. How does this legislation help build on those principles and change the way that Medicare Advantage Plans work?
DelBene: I think really the legislation was broadly built to codify the consensus statement into law. The bill would establish an electronic prior authorization process, as you said, so we can be speedy about getting information exchange. It would require HHS to establish a process for real-time decisions for items and services that are routinely approved. Again, there's no reason for something that's routinely approved to be delayed.
We wanted to improve transparency by requiring Medicare Advantage Plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials. Again, make sure that we have all of that data about what's happening because we want to continue to make sure that we are improving the experience for providers and patients, and then encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians. The more that things are standardized, the more we can see prioritization streamlined, the more that providers are spending more time providing health care versus billing app forms.
Unger: And in that spirit of standardization, do you think that this legislation could set a precedent for how prior authorization works and potentially have an impact beyond Medicare Advantage Plans in the future? In other words, could this help drive similar changes in the private insurance market?
DelBene: I definitely think so. If insurers are investing more in modernizing prior authorization systems, they should be able to leverage that. And it definitely helps providers to have it standardized across the board. And we know for individuals, it also makes a huge difference to see things move more quickly. So, I think if we see a strong improvement here that definitely has an impact more broadly.
Unger: Well, you mentioned upfront about the bipartisan support, we talked a little bit, and it's amazing to see how much bipartisan support are in the House and the Senate. You mentioned, 300 bipartisan House members, 34 senators behind this. Do you get to see that kind of bipartisan support and what's that mean to you when you see numbers like that?
DelBene: Over 300 co-sponsors is a big deal. I can't think of how many pieces of legislation that we have that have such broad support. And we are very ready to make real change here. There is a procedural issue in the House. If a bill reaches 290 co-sponsors, it starts a process that quickly moves the legislation to the floor. And if it's not moving through the regular process, we probably won't need that, because we're starting to see movement on our regular order as the terminology we would use. I know I serve on the Ways and Means Committee and the Ways and Means Committee is the committee that has jurisdiction over this. And the committee is moving towards marking up the bill next month, which is kind of that first position.
So hopefully we will see that happen in July. And if we get the bill marked up in committee, then it would move to the floor of the House for a vote. Because we have so many sponsors, we always have other ways to bring the bills to the floor. But I hope that we'll see it go through regular order and through the committee here next month to get it through the House, then we can hotline it in the Senate, which allows it to move more quickly there. So, all of the hard work that folks have done to build support to describe the challenges that the medical community has faced with this, that patients have faced, really has put us in this position. And we're starting to see that payoff.
Unger: Do you foresee any potential roadblocks to moving this forward?
DelBene: I don't see roadblocks right now, we have strong support. One of our challenges always is that finding time to move legislation because a lot of other things are trying to move at the same time. But because we have such strong support for this, I think that gives us a much better advantage. So, we're working and hopefully we'll have a firm date on when we can see this bill marked up in the Ways and Means Committee.
Unger: How are the AMA and other health care organizations supporting your efforts to get this legislation passed? And why is that kind of support so important?
DelBene: Well, the AMA and physicians have really been key to the success of this legislation. You're the ones out there who have been really describing the problem and the impact that it's having on our communities and raising that issue with lawmakers, with lawmakers across the country. And that's what's built the strong support that we see for this legislation. In the end, that's what makes the difference and helps us to move it forward.
Unger: If physicians or patients would also like to get involved and help support this legislation, what could they do?
DelBene: One thing they can do is continue to share their stories. As they say, we're not done yet. And so we need to make sure we keep pushing hard until we have a bill on the president's desk. So share your stories, they're so powerful and they continue to create that sense of urgency that we need. I just encourage folks to continue to share those stories, talk to lawmakers if you haven't yet. We have co-sponsors, there's 435 members of the House, so we'll continue to add those on until the bill moves. And then thank folks who have signed on because that has made a difference in getting us to where we are today and helps us to move forward.
Unger: I'd also like to invite physicians and patients to visit the site fixpriorauth.org for additional information on the “Improving Seniors’ Timely Access to Care Act.” And the other ways that the AMAs working to address prior authorization burdens. Representative DelBene, thank you so much for being here, that's it for today's episode. I really appreciate everything that you're doing to support physicians and patients with this work in Congress. Whether we're speaking at the AMA National Advocacy Conference in 2019 or to medical students earlier this year, you're always willing to share your time and your perspective on efforts to reform and simplify this incredibly important issue, prior authorization. So thanks again for being here.
We'll be back soon with another Moving Medicine video and podcast soon, you can find all our episodes at ama-assn.org/podcast. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.