Q&A: Talking Prior Authorization With Rep. Suzan DelBene

Although the Centers for Medicare & Medicaid Services (CMS) issued a final rule on prior authorization, there is more that can be done to ease clinician burdens in this area, according to Rep. Suzan DelBene (D-Wash.). DelBene sponsored the Improving Seniors’ Timely Access to Care Act, which would, among other provisions, require affected plans to establish an electronic prior authorization process and issue real-time decisions on routinely approved services and procedures.

As part of our occasional series of interviews with members of Congress, MedPage Today Washington Editor Joyce Frieden spoke with DelBene about what she plans to do next in this area, as well as a few other healthcare issues. The phone interview was conducted with a staff member present, and has been edited for length and clarity.

MedPage Today: Hello, and thanks for taking time to speak with us today.

Rep. DelBene: You’re welcome. Glad to speak with you.

MPT: I thought we could start with prior authorization. What’s the status of your bill now, and how has it been affected by the CMS final rule?

DelBene: Well, we definitely appreciate the rule coming forward because it actually does address many of the things that were in our bill. So this was a win. I think there were ways they could have gone further, especially in terms of speed of decision-making. [Editor’s note: The final rule requires affected plans to address non-urgent prior authorization requests in 1 week and urgent requests within 72 hours.] But this was definitely a step forward. So we’re going look to see what else we can do legislatively to not only solidify and codify what is in the rule, but also look at what we can do to try to increase speed of responses.

MPT: What does the final rule say about response time?

DelBene: We had 24 hours [in our bill] for urgent requests; we had real-time decisions for standard procedures, and that’s not in there. So those are a couple of places where we could speed things up, and that would obviously help patients and health providers be able to move more quickly.

MPT: The CMS final rule only applies to government-funded programs like Medicare, Medicaid, and the Children’s Health Insurance Program. Is there any hope of putting prior authorization rules in place for commercial health plans?

DelBene: Well, this [CMS] standard is important; it can have an impact. I think the more providers start adapting to prior authorization as running smoothly, the more impact that’s going to have more broadly.

MPT: What about having prior authorization be hooked into patients’ electronic health records? What were you hoping to see in that area?

DelBene: We want it to be electronic; we have so many providers who are still doing faxes. And I’d love to see things standardized, to have a common way that providers can put in their requests, so that they aren’t constantly in this battle with insurers who are each asking them to send a different form. We want it to be streamlined and as easy as possible so providers can spend their time taking care of patients.

MPT: Another issue I know you’re interested in is care for kidney patients. Tell us more about how you came to this issue. Is it something you’re personally connected to?

DelBene: Actually, I got into it because it has had a big impact in our region. The University of Washington was where dialysis was invented. Some of the early breakthroughs and treatments were in Washington State, so that’s actually how I got more involved with working with folks in our region [on this].

MPT: I know one of your concerns revolves around the issue of acute kidney injury and home dialysis.

DelBene: Yes, we know that 37 million Americans are living with kidney diseases. This is an issue that impacts people in every district across the country. And it impacts a huge amount of Medicare spending — nearly one in five Medicare dollars right now are helping address kidney disease. So there are things that we’ve been pushing for that could improve care for kidney patients, and one is obviously more access to home dialysis. We had a recent letter urging Medicare to expand access.

MPT: Is this something that might also be addressed through legislation?

DelBene: Yes, there are potentially things we could do legislatively also, but I think what’s key is — and COVID actually highlighted this a lot — when folks have to travel to go to a dialysis center, that reduces the amount of compliance in terms of people regularly getting dialysis, and it has a huge impact on their quality of life.

So if we can do more to get more people on home dialysis, it’s not only better for them and saves on travel, but it also means people are more likely to get dialysis when they need it. And that’s really why it’s so important. And we’ve seen huge, ongoing breakthroughs in making it easier and easier for people to have home dialysis.

MPT: I understand you also are interested in promoting research on an artificial kidney.

DelBene: Since I come from the land of innovation, we’ve been pushing real hard to make sure we’re investing in new innovation. We haven’t really seen new breakthroughs in kidney disease for over 50 years. And one huge breakthrough would be an artificial kidney, and there’s great research happening there. There are also different ways to revolutionize dialysis so that folks have easier access.

One of the ways we’ve looked at [funding this research] is through KidneyX, a public-private partnership to make sure that we have funding to give to innovators to help them really move forward on ideas that would revolutionize kidney care. We’re continuing to push for more KidneyX funding so that we are able to get more innovators to continue to help fund that next great breakthrough.

MPT: There’s one other area I wanted to ask about: what are your thoughts on the cuts to the Medicare physician fee schedule that recently took effect?

DelBene: You know, physician payment has declined by 26% over the last few decades when you adjust for inflation. And the cut that just took place on January 1st continues to widen the gap between the true cost of care and what Medicare is reimbursing.

So we need two things: we need a short-term fix and we need a long-term solution. Because what’s so terrible is, this is coming up over and over and over again. It’s hard on providers to keep up [financially]. We know that that has a huge impact on Medicare patients, especially with less doctors being able to participate, and so it makes it harder to find doctors or to get great quality of care.

So we need to find a permanent solution to this. I’m a co-sponsor of the Strengthening Medicare for Patients and Providers Act, which would peg this payment to inflation so that we aren’t seeing the decline happen all the time.

MPT: Well, thank you again for speaking with us today.

DelBene: Absolutely. Thank you.