[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
UTILIZATION MANAGEMENT: BARRIERS TO CARE AND BURDENS ON SMALL MEDICAL
PRACTICES
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
SEPTEMBER 11, 2019
__________
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Small Business Committee Document Number 116-043
Available via the GPO Website: www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
37-560 WASHINGTON : 2019
--------------------------------------------------------------------------------------
HOUSE COMMITTEE ON SMALL BUSINESS
NYDIA VELAZQUEZ, New York, Chairwoman
ABBY FINKENAUER, Iowa
JARED GOLDEN, Maine
ANDY KIM, New Jersey
JASON CROW, Colorado
SHARICE DAVIDS, Kansas
JUDY CHU, California
MARC VEASEY, Texas
DWIGHT EVANS, Pennsylvania
BRAD SCHNEIDER, Illinois
ADRIANO ESPAILLAT, New York
ANTONIO DELGADO, New York
CHRISSY HOULAHAN, Pennsylvania
ANGIE CRAIG, Minnesota
STEVE CHABOT, Ohio, Ranking Member
AUMUA AMATA COLEMAN RADEWAGEN, American Samoa, Vice Ranking Member
TRENT KELLY, Mississippi
TROY BALDERSON, Ohio
KEVIN HERN, Oklahoma
JIM HAGEDORN, Minnesota
PETE STAUBER, Minnesota
TIM BURCHETT, Tennessee
ROSS SPANO, Florida
JOHN JOYCE, Pennsylvania
Adam Minehardt, Majority Staff Director
Melissa Jung, Majority Deputy Staff Director and Chief Counsel
Kevin Fitzpatrick, Staff Director
C O N T E N T S
OPENING STATEMENTS
Page
Hon. Nydia Velazquez............................................. 1
Hon. Steve Chabot................................................ 2
WITNESSES
Dr. Paul M. Harari, Professor, Chairman, Department of Human
Oncology, University of Wisconsin School of Medicine and Public
Health, Madison, WI, testifying on behalf of the American
Society for Radiation Oncology (ASTRO)......................... 4
Dr. David R. Walega, MSCI, Associate Professor of Anesthesiology,
Chief, Division of Pain Management, Vice Chair of Research,
Department of Anesthesiology, Northwestern University Feinberg
School of Medicine, Chicago, IL, testifying on behalf of the
American Society of Anesthesiologists.......................... 6
Dr. John S. Cullen, FAAFP, Family Physician & Partner, Valdez
Medical Clinic, LLC, Valdez, AK, testifying on behalf of the
American Academy of Family Physicians.......................... 7
Dr. Howard Rogers, PhD., FAAD, Owner, Advanced Dermatology, LLC,
Norwich, CT, testifying on behalf of the American Academy of
Dermatology Association........................................ 9
APPENDIX
Prepared Statements:
Dr. Paul M. Harari, Professor, Chairman, Department of Human
Oncology, University of Wisconsin School of Medicine and
Public Health, Madison, WI, testifying on behalf of the
American Society for Radiation Oncology (ASTRO)............ 27
Dr. David R. Walega, MSCI, Associate Professor of
Anesthesiology, Chief, Division of Pain Management, Vice
Chair of Research, Department of Anesthesiology,
Northwestern University Feinberg School of Medicine,
Chicago, IL, testifying on behalf of the American Society
of Anesthesiologists....................................... 37
Dr. John S. Cullen, FAAFP, Family Physician & Partner, Valdez
Medical Clinic, LLC, Valdez, AK, testifying on behalf of
the American Academy of Family Physicians.................. 42
Dr. Howard Rogers, PhD, FAAD, Owner, Advanced Dermatology,
LLC, Norwich, CT, testifying on behalf of the American
Academy of Dermatology Association......................... 52
Questions for the Record:
None.
Answers for the Record:
None.
Additional Material for the Record:
America's Health Insurance Plans (AHIP) and the Blue Cross
Blue Shield Association (BCBSA)............................ 60
American Academy of Ophthalmology............................ 67
American Physical Therapy Association (APTA)................. 72
Consenus Statement on Improving the Prior Authorization
Process.................................................... 81
Dr. Josh Bailey, PT, DPT, CEO, Rehabilitation Associates on
behalf of the Virginia Physical Therapy Association........ 85
Final Stakeholder of the American Association of Neurological
Surgeons/Congress of Neurological Surgeons................. 89
UTILIZATION MANAGEMENT: BARRIERS TO CARE AND BURDENS ON SMALL MEDICAL
PRACTICES
----------
WEDNESDAY, SEPTEMBER 11, 2019
House of Representatives,
Committee on Small Business,
Washington, DC.
The committee met, pursuant to call, at 11:32 a.m., in Room
2360, Rayburn House Office Building. Hon. Nydia Velazquez
[chairwoman of the Committee] presiding.
Present: Representatives Velazquez, Finkenauer, Kim,
Davids, Chu, Evans, Schneider, Delgado, Houlahan, Craig,
Chabot, Balderson, Hern, Hagedorn, Stauber, Burchett, and
Joyce.
Chairwoman VELAZQUEZ. Good morning. The committee will come
to order.
I thank everyone for joining us this morning, and I want to
especially thank the witnesses who have traveled from across
the country to be here with us today.
On this committee, we are focused on breaking down barriers
that many small businesses face. Whether it is ensuring small
firms have access to affordable capital or reducing regulatory
burdens, our focus on this committee is to create a thriving
Main Street that makes towns and communities across the country
better places to live, work, and raise a family.
An essential part of any community are the doctors who are
relied upon in every corner of our country to keep us healthy.
But what many people forget is that many doctors, especially in
rural and underserved communities, are themselves small
businesses. They face the same challenges that any small
employer encounters--making payroll, paying rent, managing
overhead expenses, while also dealing with the same regulations
that larger hospitals can manage through bigger budgets and
more resources. However, when doctors spend hours dealing with
paperwork or cannot treat a patient because a health insurance
company will not approve a treatment, the result is patients
suffering.
And that is why we are here today--to discuss a barrier
preventing family physicians and specialists from providing
critical care to their patients. Prior authorization is a cost-
savings tool used to reduce healthcare spending through
improper payments and unnecessary care. Before doctors can
provide even routine care procedures, diagnostic tests, or
prescriptions, they must first obtain approval from a patient's
insurer. While in some cases this process leads to appropriate
treatments, reduces costs by eliminating expensive tests or
unnecessary prescriptions, it also is putting an undue burden
on physicians, their staff, and patients.
It is not uncommon that patients now face delays of 2 weeks
and sometimes over a month before getting treatment. In fact,
more than 25 percent of doctors report that prior authorization
has led to a serious adverse event for a patient in their care.
And, 82 percent report the burdens associated with prior
authorization lead to delayed care. Meanwhile, doctors are
sitting on hold with insurance companies to explain why their
patient needs a certain treatment.
Sadly, this is an issue impacting doctors practicing in
nearly every area of medicine in every part of the country. It
affects each doctor paid by insurance, but is especially
problematic for small group and solo practitioners that simply
do not have the resources to hire additional administrative
staff.
Between the massive student loan debt many doctors face and
these administrative burdens, it is no wonder that many doctors
are deterred from pursuing the great American dream--to own and
operate their own business.
By 2030, the Association of American Medical Colleges
expects the workforce shortage to expand to over 100,000
doctors nationwide. One way to combat this growing problem is
to empower small private practices to fill the gaps. They can
do this with common sense policies that streamline the prior
authorization process--making it easier for them to do what
they were trained to do--keep our communities healthy.
I support reducing costs because our country spends nearly
double the amount per person in health care than any other
industrialized nation, yet our population ranks near the bottom
in health outcomes compared to other high-income countries.
There are reasonable ways to reduce costs such as
increasing transparency in pricing so that consumers know what
they are paying, allowing the government to negotiate the
prices of prescription drugs so that our seniors can access
affordable prescriptions, and increasing the use of technology.
I am excited to hear about the potential solutions to this
problem so that patients can get the care they need. I look
forward to hearing about how we can modernize and streamline
this process so that doctors can stop wasting time haggling
with health insurance companies and continue to make the lives
of patients and their families better.
Again, I want to thank the witnesses for being here today,
and I now yield to the Ranking Member, Mr. Chabot, for his
opening statement.
Mr. CHABOT. Thank you, Madam Chair.
We are here today to hear from medical professionals about
the burdens experienced by small medical practices, especially
utilization management. The medical field is an integral part
of our everyday lives. All participants from world renowned
surgeons to clerical and administrative staff in this field
deserve recognition for their diligent efforts to save lives.
As we in Ohio know all too well, medical professionals are
on the frontlines fighting the opioid epidemic. In 2016, there
were over 42,000 deaths due to opioid overdose. This statistic
is one of the reasons prior authorization has been implemented
to help those in my home state and across the nation. Methods
such as STEP therapy and prior authorization were introduced to
reduce unnecessary procedures, prevent oversubscription of
dangerously addictive drugs, and reduce human error.
However, despite the reasoning for these processes, more
must be done to streamline communication between practices and
insurance providers. Many small medical practices struggle to
afford necessary staff to complete the almost 60 extra hours
spent per week on administrative tasks. Doctors spend extra
time on the complex processes and paperwork required for prior
authorization instead of tending to their patients. Patients
become frustrated and 40 percent will abandon prescriptions
requiring prior authorization at the pharmacy.
While this may sound grim, there is still hope, and we are
looking for solutions. Increased collaboration between private
insurers and organizations like the AMA can ensure prior
authorization requests are based on sound medical science.
I want to thank the witnesses for sharing their experiences
with us here, if we ever stop talking. I look forward to
discussing solutions to reduce the burdens on small providers
and ensure a more efficient healthcare system.
And Madam Chairwoman, I appreciate you holding this
hearing. I think this is one of the more important hearings
that we have had this year. So, thank you for doing that. And
thank the witnesses for coming today.
Chairwoman VELAZQUEZ. Thank you, Mr. Chabot.
The gentleman yields back.
And if committee members have an opening statement
prepared, we will ask that they be submitted for the record.
I would like to take a minute to explain the timing rules.
Each witness gets 5 minutes to testify and members get 5
minutes for questioning. There is a lighting system to assist
you. The green light will be on when you begin, and the yellow
light comes on when you have 1 minute remaining. The red light
comes on when you are out of time, and we ask that you stay
within the timeframe to the best of your ability.
I would now like to introduce our witnesses.
Our first witness is Dr. Paul Harari. Dr. Harari is the
Jack Fowler Professor and Chairman of the Department of Human
Oncology at the University of Wisconsin School of Medicine and
Public Health. He joined the faculty at the University of
Wisconsin in 1990 and became an endowed professor in 2003 and
the Department Chairman in 2007. His clinical and laboratory
research focuses primarily on treatment advances for head and
neck cancer patients.
Thank you, Dr. Harari, for being here today.
Our second witness is Dr. David Walega. Dr. Walega is
currently the Chief of the Division of Pain Medicine at
Northwestern Medicine and the Vice Chair of the Department of
Anesthesiology at Northwestern University Feinberg School of
Medicine in Chicago, where he has been a faculty member since
2003. He earned his medical doctorate from Wayne State
University in Detroit in 1993 and completed an internship in
internal medicine and a residency at Northwestern University.
He is a dedicated medical educator and holds the rank of
associate professor at Northwestern University, where he has
published numerous manuscripts and book chapters on pain-
related topics and has lectured nationally and internationally.
Thank you, Dr. Walega, for being here this morning.
Our third witness is Dr. John Cullen, a family physician in
Valdez, Alaska, and the president of the American Academy of
Family Physicians, which represents 134,600 physicians and
medical students nationwide. Dr. Cullen earned his Bachelor of
Science in molecular and cell biology from the University of
California-San Diego. He earned his medical degree from the
University of Arizona College of Medicine-Tucson.
Thank you, Dr. Cullen, for being here this morning.
And now I yield to our Ranking Member, Mr. Chabot, to
introduce our final witness.
Mr. CHABOT. Madam Chairwoman, our final witness is Dr.
Howard Rogers, testifying on behalf of the American Academy of
Dermatology. Dr. Rogers is a graduate of Harvard University and
holds both an MD and PhD from Washington University School of
Medicine. Dr. Rogers completed a fellowship in my congressional
district at the University of Cincinnati Hospital. He now owns
a private dermatological practice in Connecticut, where he has
treated approximately 35,000 cases of skin cancer in the last
19 years.
We welcome you here, Dr. Rogers, and thank you for
testifying today.
Chairwoman VELAZQUEZ. Thank you, Mr. Chabot.
Dr. Harari, you are now recognized for 5 minutes.
STATEMENTS OF DR. PAUL M. HARARI, PROFESSOR, CHAIRMAN,
DEPARTMENT OF HUMAN ONCOLOGY, UNIVERSITY OF WISCONSIN SCHOOL OF
MEDICINE AND PUBLIC HEALTH; DR. DAVID R. WALEGA, MSCI;
ASSOCIATE PROFESSOR OF ANESTHESIOLOGY, CHIEF, DIVISION OF PAIN
MANAGEMENT, VICE CHAIR OF RESEARCH, DEPARTMENT OF
ANESTHESIOLOGY, NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF
MEDICINE; DR. JOHN S. CULLEN, FAAFP,FAMILY PHYSICIAN & PARTNER,
VALDEZ MEDICAL CLINIC, LLC; DR. HOWARD ROGERS, PHD, FAAD,
OWNER, ADVANCED DERMATOLOGY, LLC
STATEMENT OF DR. PAUL M. HARARI
Dr. HARARI. Chairwoman Velazquez, Ranking Member Chabot,
and esteemed members of the Small Business Committee, thank you
very much for the opportunity to testify before you today on
barriers to health care and burdens on the physicians. I am
testifying on behalf of the American Society for Radiation
Oncology (ASTRO). I serve as the Chairman of ASTRO's Board of
Directors and Professor and Chairman of Radiation Oncology at
the University of Wisconsin.
ASTRO represents more than 10,000 members who strive to
give cancer patients the best possible care to advance the
science of oncology. ASTRO's membership includes radiation
oncologists, nurses, biologists, medical physicists, and other
healthcare professionals who specialize in treating patients
with radiation therapy. Our members work in hospitals, academic
research institutions, private practices, and this year, more
than 1.7 million people will be diagnosed with cancer in the
U.S., and roughly 1 million of these will receive radiation
therapy.
Today, I wish to share with you a major problem that you
have identified today. This one also facing the field of
radiation oncology, prior authorization. While the system may
have been designed as a path to streamline healthcare, in fact,
it is frequently harmful to cancer patients in receiving
treatment.
There are three issues I would like to highlight today.
First, prior authorization wastes precious time that
physicians could be devoting to patient care.
Second, delays in cancer care can have negative impacts on
patient outcomes.
And third, this disproportionately impacts providers in
small community practice settings.
Prior authorization has become an overly bureaucratic
process that requires physicians to obtain approval from health
insurance companies to prescribe a specific treatment,
procedure, or medication. Radiation oncologists are
increasingly restricted from exercising their clinical judgment
in the best interest of their patients. Instead, insurance
companies and third-party payers are making clinical decisions
for these cancer patients. Who would you want to make cancer
care decisions for you--your insurance company or your cancer
physician?
In a recent ASTRO survey, 9 of 10 radiation oncologists
reported patient treatment delays due to the prior
authorization process. In cancer care, timely treatment
matters. Yet, prior authorization practices are delaying
patients from receiving life-saving therapies, literally
putting the lives of millions of people at risk.
In my own practice at the University of Wisconsin
Comprehensive Cancer Center we have 16 busy radiation
oncologists who routinely face treatment delays for their
patients related to prior authorization. Let me provide a
personal example. When a prior authorization is denied despite
the best efforts of my administrative staff and resident
physicians, I may be called upon to conduct a peer-to-peer
review by phone. This occurred for a patient of mine with a
complex base of skull tumor. The peer reviewer was a thoughtful
general practitioner who was unfamiliar with base of skull
chordoma and unfamiliar with radiation and asked me for several
minutes about the tumor, the natural history, the anatomy, the
normal structures nearby, and before concluding said, Dr.
Harari, you are obviously highly expert in this area. I will
authorize the radiation treatment just as you prescribe.
Meanwhile, my patient had been anxiously awaiting for 8 days
while that tumor was growing to learn confirmation that they
could receive the prescribed cancer treatment that was
recommended.
The problems associated with prior authorization are so
pervasive that 2/3 of radiation oncologists surveyed have had
to hire new staff to handle these requests. In an era of value-
based care, where is the value when we are increasing costs to
deliver care without any added clinical benefit? The issue of
prior authorization is concerning for patients who receive
treatment in private practices who often have less staff to
handle these requests.
In 2018, a report from the Office of the Inspector General
stated that Medicare Advantage organizations may have an
incentive to deny preauthorization of services in order to
increase profits. In the same report, it was revealed that CMS
had acknowledged widespread and persistent performance problems
related to inappropriate denials of care and payment.
In conclusion, legislation is needed to relieve radiation
oncology patients and physicians of the burden from restrictive
prior authorization. Members of this body can put themselves in
the shoes of a newly diagnosed cancer patient to appreciate the
significantly negative impact that treatment delays can have on
their lives. ASTRO looks forward to working with policymakers
and stakeholders to develop policy-based solutions to fix this
broken system.
Thank you very much.
Chairwoman VELAZQUEZ. Thank you very much, Dr. Harari.
Dr. Walega, you are now recognized for 5 minutes.
STATEMENT OF DR. DAVID R. WALEGA
Dr. WALEGA. Chairwoman Velazquez, Ranking Member Chabot,
and members of the Committee, thank you for the opportunity to
testify before the House Committee on Small Business today. I
offer this testimony on behalf of the American Society of
Anesthesiologists (ASA) and my colleagues who practice pain
medicine.
Physicians like me are all too familiar with the burdens of
prior authorization and the toll it takes on our patients and
our medical practices. Because of our current broken insurance
system, physician time and practice resources are increasingly
allocated to fighting insurers instead of caring for patients.
It is a system built to fail.
Presently in medicine we are facing dual crises. First, we
have the opioid epidemic. Second is the crisis of chronic pain.
The most recent statistics on the prevalence of chronic pain
conditions in the United States is staggering.
I would like to tell you about a patient of mine who I will
call Betsy, to illustrate the complicated interaction of these
dual crises and the predicament many pain specialists like me
encounter daily.
Betsy is 38. She came to me with a 10-year history of back
pain and nerve pain in her legs following a failed spine fusion
surgery. When I saw her she was dependent on high doses of
opioids to manage her pain, and despite these high doses, her
pain was not under control. She felt hopeless. She had seen
multiple doctors and the cycle of this pain had been going on
for years. That day in my office she tearfully pleaded, is
there anything you can do for me? After examining her, I knew
Betsy would be an ideal candidate for a non-opioid treatment
for chronic pain called spinal cord stimulation (SCS). This is
a treatment in which we surgically place small stimulating
electrodes adjacent to the spinal cord to deliver imperceptible
electrical impulses to the spinal cord to block pain signals
from being transmitted to the brain.
To make sure this treatment would be effective for Betsy, I
recommended that she taper her opioids by at least 50 percent
before we would proceed with treatment as high doses of opioids
can cloud the effects of stimulation. Surprisingly, that day
she tapered completely off of all of her medications. Per
standard practice, I first implanted a temporary spinal cord
stimulating system for a 10-day trial. Her health insurance
provider did approve this. During the trial, we want to see at
least a 50 percent reduction in a patient's pain with a
commensurate improvement in their physical function.
In Betsy's case, the gains with her temporary trial were
nothing less than astounding. She became a completely different
person. Her face had brightened, she moved around my office
with ease. I heard her laugh for the first time. She told me
that during the trial she went for walks around the
neighborhood with her husband, something she had not been doing
for years. She was able to play with her two children who have
special needs. For those 10 days she had her life back and she
was ecstatic.
So I submitted the required forms and letters of medical
necessity to her insured to obtain authorization to implant a
permanent spinal cord stimulation system. That implant was
denied by her insurer. I appealed the denial which was denied
again. I appealed again and requested a peer-to-peer review.
The concept behind the peer-to-peer review is that another
physician chosen by the insurer objectively reviews the medical
necessity of a proposed treatment and speaks directly to me,
the provider.
Unfortunately, peer-to-peer is a misnomer as the physician
reviewer, as previously stated, is usually not a similarly
trained or experienced specialist in the field. In fact, I have
had a general pediatrician review prior cases like this one.
In Betsy's case, the appeals process took 8-1/2 months.
Feeling hopeless and experiencing intolerable levels of pain
again after the temporary system was removed, Betsy went back
on opioids to control her pain. She lost hope all over again
even though we had a proven treatment that was effective for
her.
It was my appeal to the medical director to her insurance
company that got the treatment finally approved. Today, Betsy
has her spinal cord stimulator. She is not taking opioids. She
is taking care of her kids. She is independent and she is
returning to the workforce. She has her life back. Betsy's
ultimate clinical outcome is the reason I became a physician,
to help patients live their best lives despite an underlying
medical condition.
Physicians do not have the resources to fight this type of
fight for every single patient, not in our current practice
environment. These appeals take precious time away from
providing care that other patients need, and for these reasons
I am appreciative that the Committee is looking critically at
this issue.
In my submitted written testimony, I have included specific
recommendations to remove barriers to comprehensive
multidisciplinary pain care, as well as substance use disorder
treatment. And I thank you for your consideration this morning.
Chairwoman VELAZQUEZ. Thank you, Dr. Walega.
Dr. Cullen, you are now recognized for 5 minutes.
STATEMENT OF DR. JOHN S. CULLEN
Dr. CULLEN. Chairman Velazquez, Ranking Member Chabot, and
members of the Committee, I am honored to be here today
representing the 134,600 members of the American Academy of
Family Physicians.
I am a practicing family physician in Valdez, Alaska, a
community of about 4,000 people. I am also a small business
owner and a partner of the Valdez Medical Clinic, LLC, and
along with five family physician colleagues, we are the sole
providers for a geographically isolated community 300 miles
from the nearest tertiary care hospital, and the area we serve
is about the size of Ohio.
The AFP welcomes this hearing on utilization management as
an important and necessary step towards reducing both barriers
to care for patients and the administrative burdens for family
physicians. As I detail in the written testimony, family
physicians and their patients face a daunting array of
administrative barriers to appropriate and necessary medical
care. The result has been chaos in caring for our patients,
burnout for family physicians, and worse outcomes for patients.
Ask any practicing family physician about preauthorization and
you are going to get an earful.
Prior authorization is a major reason that small practices
like mine are closing. In my own practice, a patient of mine
had a combination of Crohn's Disease and severe psoriasis and
we eventually controlled both disorders with a monoclonal
antibody therapy after years of trying multiple other regimens
and with consultation with multiple specialists. After 2 years,
we had to reauthorize this medication which had been working so
well, and that resulted in a delay of months, during which her
condition worsened. And when we finally were able to get her
back on the medication, she had a serum sickness reaction and
suffered anaphylactic shock and we almost lost her. And she can
now never use this medication that was working so well.
Most family physicians in private practice have contractual
relationships with seven or more insurance companies, including
Medicare and Medicaid, and now our practice, and again, I am in
a town of 4,000 people, has 35 different insurance plans we
deal with, each of which has its own system of prior
authorization and drug formularies, and which change on a
regular basis. I often do not know in advance which medications
in which class will be covered, and this often means that when
I wrote a prescription, my patient has to take it to the
pharmacy to find out if it is covered. And if it is not, then I
need to find an alternative often by writing a new prescription
and the process gets repeated.
We use electronic preauthorization but we do not often get
a timely answer and this leads to a phone call by me or one of
my staff to a reviewer who often has a very hazy idea about the
difference between generic and tradenames or even what the
medication does.
My patients rarely blame their insurance company for this
administrivia. They blame me for not getting them the
medications they need, yell at my staff, or just stop taking
the medications they need to prevent hospitalization. And this
is the hidden cost of prior authorization. My staff burn out
and quit because of the frustration inherent in this crazy
system, compounded by being yelled at by patients for not
having their medications.
So I was just told before I came here that my nursing
supervisor is quitting next month. And she and one of my MAs is
spending their entire time just doing prior authorizations. And
that is not what she trained for.
In the recent 2019 AFP survey, administrative burden was by
far the top issue facing family physicians, of which EMRs and
prior authorizations for medications, durable medical
equipment, and procedures such as imaging were the most
impactful. Prior authorization for durable medical equipment
typically requires a physician to fill out a paper form or
submit specific data for approval, and each DME company has
different data requirements for submission. We are being pelted
with DME forms.
Family physicians simply want to be able to prescribe
efficiently and effectively what their patients need to help
them manage their condition in a way that maintains their
health.
And we know how to fix it. America's frontline physicians
have developed joint principles on reducing administrative
burden in health care. The AFP strongly urges the adoption of
the prior authorization and STEP therapy recommendations that
we shared in our written testimony. We call for prior
authorizations to be minimized, standardized, and universally
electronic to promote efficiency and reduce administrative
burdens that direct valuable resources away from patient care
and can inadvertently lead to negative patient outcomes.
We support the Improving Seniors Timely Access to care Act,
H.R. 3107. It is a bipartisan effort. It is a step in the right
direction and will protect Medicare Advantage patients by
streamlining prior authorization practices.
The prior authorization practice is out of control. It is
increasing, and rather than a tool for preventing unnecessary
or expensive care, prior authorizations negatively impact
patients' health, and is a significant cause for family
physician burnout and the closure of small private practices.
So thank you very much for your interest in reducing both
barriers to care for patients and administrative burdens on
family physicians.
Chairwoman VELAZQUEZ. Thank you, Dr. Cullen.
Dr. Rogers, you are now recognized for 5 minutes.
STATEMENT OF DR. HOWARD ROGERS
Mr. ROGERS. Thank you, Chairwoman Velazquez, Ranking Member
Chabot, and members of the Small Business Committee, for the
opportunity to speak before you today on behalf of the American
Academy of Dermatology Association.
I am Dr. Howard Rogers, board-certified dermatologist, and
I own a small private practice, Advanced Dermatology, in
Connecticut. As a small business owner, I appreciate the
Committee's efforts to prioritize reducing administrative
burden such as utilization management processes. My testimony
will focus on how increasing administrative burdens are
impacting small medical practices such as my business, and more
importantly, I will highlight how prior authorizations delay
necessary care for patients.
Physicians' practices are on the frontlines of the
healthcare system. Right now, while our country is grappling
with how to increase patient access to high quality care while
reducing costs, my colleagues and I are forced to comply with
utilization management systems that seem designed to force
doctors out of practice.
I and other physicians in my practice dedicate at least 15
hours a week on prior authorizations alone. Prior auths drive
up the cost of running a medical practice. They routinely delay
critical patient care and contribute to physician burnout while
providing no increase in quality of care.
Dermatologists diagnose and treat more than 3,000 diseases.
For many skin diseases and conditions, the medications are
specialized and their use is highly nuanced, and it is
dependent on numerous factors specific to the patient and his
or her disease. Prior authorization policies place a third
party in the decision-making position with little or no
understanding of the complexity or full history of a patient's
condition.
So just imagine seeing a patient in your office with a
severely painful condition or a rapidly spreading infection.
You prescribe a highly effective medication, you walk the
patient through how they are going to use that medication, and
you assure the patient that they are going to soon feel better.
Then the following scenario occurs. The prescription is denied
because prior authorization is required and you try for days or
weeks to get that medication approved while the patient
continues to suffer. The patient goes to the pharmacy
repeatedly and is told that the medication is denied, is no
longer covered, requires a prior authorization, and there is
nothing they can do about it. You can imagine the frustration
and desperation of patients when they are at their most
vulnerable.
So in my office, my staff spent 70 hours a week, 70 hours a
week on prior auths alone. I have had to hire two full-time
staff at the cost of $120,000 a year with salary and benefits
to handle the volume of prior auths. These funds could
definitely be better spent on staff education, improved benefit
packages for staff, new medical equipment, technology, all
those things that bring us forward as physicians.
We appreciate Congress working to help alleviate the prior
authorization burdens by including language to create a
standardized electronic prior authorization form for Medicare
or prescription drugs in the support for Patients and
Communities Act which passed in October 2018.
Prior authorizations are also delaying patient access to
necessary dermatologic procedures. Mohs micrographic surgery is
a technique that dermatologists use to surgically excise skin
cancers, ensuring in real time that the malignancy is fully
treated while sparing as much healthy tissue as possible.
Typically, Mohs surgery does not require a prior auth. However,
the reconstruction of the defect left after the surgical
excision does. And since the physician does not know the extent
of the repair procedure that will be needed prior to the
surgery, obtaining the prior authorization is not possible. And
so this leaves the physician, me, with a patient with a hole in
their skin and no authorization to repair it. By prohibiting
plans from requiring prior authorization during skin cancer
surgery, patients will be ensured the best chance of positive
outcome.
To address this burden, we ask the members of the Committee
to support the Improving Seniors Timely Access Care Act (H.R.
3107). This legislation aims to relieve prior authorization
burdens for procedures under Medicare Advantage Plans, as well
as to provide transparency to patients and providers.
So it is impossible for me to capture in these remarks how
the prior authorization process hinders the practice of
medicine. Even with the extra support staff, the providers in
my practice are regularly disrupted from patient care to deal
with prior auths. In fact, 1/4 of all communications in my
office, be it phone calls, faxes, emails, EMR notifications,
payer portals, they are all associated with prior
authorizations.
And the kicker is that most of my patients' prescriptions
and repairs eventually get approved but only after exhaustive
efforts of calling insurers and appealing denials. However, the
process truly wears down my colleagues and staff to the point
where I worry about burnout for them. We became physicians to
help patients, not complete paperwork. And the constant
struggle has become too much for many of my colleagues,
including my practice partner who is retiring despite being in
good health and loving seeing his patients. Prior authorization
ultimately ends up costing the healthcare system more than it
saves.
So on behalf of the American Academy of Dermatology
Association, I thank you for holding this hearing and your
interest in safeguarding physicians and patients from
unnecessary utilization management practices. And I am happy to
answer any questions.
Chairwoman VELAZQUEZ. Thank you, Dr. Rogers.
Let me take this opportunity to thank all of you for your
insightful testimonies, and specifically for putting a human
face into the issue of prior authorization.
I would like to ask each one of you, how often do you have
to delay the start of treatment because of the prior
authorization process?
Dr. HARARI. Chairwoman, the survey that ASTRO conducted of
all radiation oncologists recently identified that 9 in 10
radiation oncologists have patients with treatment delays. As
many as 2/3 of patients will experience a delay in the start of
their cancer treatment related to prior authorization.
Chairwoman VELAZQUEZ. Yes?
Dr. CULLEN. And I guess I am speaking just from a personal
perspective but we have at least three or four a day if not
more, just in my own, the patients that I am seeing.
Chairwoman VELAZQUEZ. So in your view, are these health
insurance companies that you have to deal with equipped to
determine the course of action or the course of treatment that
is best for your patients?
Dr. WALEGA. I would like to answer that.
Chairwoman VELAZQUEZ. Has there been any study conducted to
that effect?
Dr. WALEGA. As far as studies, I do not know but as I think
we all commented, the individuals who are ultimately making the
decision about our patients' fate and how their health care
will be directed is made by someone who does not do what we do.
They do not see the patient. They probably have not looked at
the medical records that we have sent to them repeatedly, and
they often do not know the latest technology that we are
applying in these cases of treatment.
Chairwoman VELAZQUEZ. So are you telling me that you do not
know what type of data or scientific evidence the health
insurance companies are using when making a decision?
Dr. HARARI. I can tell you that there is very strong,
robust scientific data that delaying cancer treatment can
decrease survival. There are dozens of papers identifying each
week of delay for fast growing tumors can knock off 1 or 2 or 3
percent of the cure aid. I am aware of no scientific data that
the insurance companies provide as to why those delays are
acceptable.
Chairwoman VELAZQUEZ. In a 2018 report, and I believe that
some of you mentioned it, the OIG stated that, and I quote,
``Medicare Advantage organizations may have an incentive to
deny preauthorization of services in order to increase
profits.''
To the entire panel, based on your experience, do you find
this to be true? In other words, is this cost-saving measure
used by insurers really a disguise that allows them to increase
their profits at the expense of patients? And at the expense of
the bottom line of your practices?
Dr. HARARI. I am sorry to say that I think that this is
true. This is certainly the experience of the radiation
oncologists across the U.S. that were surveyed, identifying
that 2/3 of the prior authorization denials were subsequently
overturned on appeal, suggesting that the incentives that are
derived by healthcare benefit managers may be prioritizing
their actions over what is best for the individual cancer
patient.
Chairwoman VELAZQUEZ. Yes, Dr. Cullen?
Dr. CULLEN. So I think for us one of the best examples is
albuterol. Albuterol is an inhaler used for asthma. But I have
to decide whether the insurance company will accept albuterol
or whether they will accept ProAir or whether they will accept
Ventolin. They are all the same thing. But it really depends on
which one that insurance company will accept at that moment in
time. And a lot of that is based on agreements that they have
with pharmacy benefit managers.
Another good example is we start joking about the PPI de
jour. That is the proton pump inhibitor of the day because
those change on a regular basis. We are never informed about
what those changes are but these are common medications.
I was talking earlier that I had to preauthorize
hydrochlorothiazide which is a blood pressure medication that
has been used forever and has a great safety track record. It
is very inexpensive, but I had to prior authorize even that
medication as a generic. So unfortunately, I think that that is
the case.
Chairwoman VELAZQUEZ. Dr. Rogers?
Mr. ROGERS. Unfortunately, there is little or no
transparency in how the prior authorizations are judged, nor
the guidelines by which the reviewers look at the clinical
information provided. It seems haphazard, and it is designed to
wear the physician down to the point where care is not
rendered, which would definitely increase profitability for the
insurers.
Chairwoman VELAZQUEZ. I do not have much time left but I
would like to ask the following question and see which one of
you would like to answer.
Do the third-party benefit management companies, Medicare
Advantage plans, hired to conduct prior authorization also have
this perverse incentive?
Dr. HARARI. I believe so because it is reflected in the
overwhelming number of prior authorization denials that are
then subsequently overturned after 2 to 3 weeks of fussing back
and forth.
Chairwoman VELAZQUEZ. I ran out of time. Thank you so very
much.
And now I recognize the Ranking Member, Mr. Chabot.
Mr. CHABOT. Thank you, Madam Chair.
Dr. Rogers, I will go with you first. In your opening
statement you mentioned not being able to complete surgery for
the patient because of prior authorization. Could you explain
how on an everyday basis this actually works in the office and
what specifically about prior authorization hinders the
process? Just how does it make it that much more complicated
than everything else?
Mr. ROGERS. Sure. I would love to give you an example.
So just a few days ago I was operating on a patient, and
unexpectedly, the skin cancer that was on her nose extended all
the way through from the outside to the inside resulting in a
full thickness defect. In that sort of scenario, the
reconstructive codes that are going to need to be used are, you
know, extensive. And so I immediately asked my nurse, get on
the phone to her Medicare Advantage plan and get prior
authorization. So after an hour of being on the phone, the
nurse said they are going to get back to us in a few days. But
the woman, who if I do not properly reconstruct this nose, it
is going to collapse. She is not going to be able to breathe
properly and the cosmetics of it will be severely affected. So
in that sort of scenario I go ahead and perform the
reconstruction including cartilage grafting and flap
reconstructions with the distinct possibility that there will
be no payment on the end.
Mr. CHABOT. Thank you very much, Doctor.
Dr. Cullen, many states have recently passed laws on STEP
therapy protocols that would benefit doctors, patients, and
insurers. Do you think these legislative efforts can improve
some of the burdens that you have described with prior
authorizations?
Dr. CULLEN. I think specifically reducing the amount of
time to get a response, those kind of legislations have been
shown to be invaluable. I, unfortunately, have not been able to
experience any of these personally because Alaska has not done
either one of those as far as STEP therapy or timeliness in
response. We would like to see the STEP therapy though
drastically reduced as an academy because we do not see that as
being a valuable way to pursue this.
Mr. CHABOT. Okay. Thank you very much, Doctor.
Dr. Walega, according to CDA data, most opioids are not
prescribed by physicians such as yourself but rather primary
care physicians or dentists. Are prior authorization
requirements for opioids worth the extra time it takes if it
helps keep addictive medications at bay?
Dr. WALEGA. First of all, I would like to mention that the
number of opioid prescriptions in the United States is going
down and the number of deaths related to prescribed opioids has
also precipitously dropped. The deaths that we are seeing is
primarily from recreational use, basically street drugs, heroin
and fentanyl.
As far as the pathway of primary care physicians writing
for opioids as well, I think we have made tremendous gains in
educating providers, primary care providers, as well as
ancillary providers with regard to not going to opioids first,
and if opioids are going to be prescribed, having much more
tight guidelines, practice guidelines around that. Urine drug
screening on a regular basis if the prescribing will continue.
Having the patient read and sign and agree to an opioid
agreement which states the prescriber will be the only
prescriber. The patient will take the medication as prescribed,
not run out early, not double the dose, not treat themselves
without the provider's input.
So that problem, I think, is decreasing. We still do see
the CDC guidelines on opioid prescribing misappropriate or
misapplied wherein here is a CDC rule that says do not
prescribe more than X amount of drug per day to all patients,
and that is misapplied. We have patients who have done very
well on doses of opioids higher than that doing well, showing
no use of substance use disorder. And that medication is being
denied at times.
Mr. CHABOT. Thank you, Doctor. I appreciate it.
I want to get one to Dr. Harari real quickly.
Doctor, Cincinnati Children's Hospital in my congressional
district helps community practices with their billing and
software needs. Do you know of any other hospital systems that
do this?
Dr. HARARI. There are. There certainly are. We have at the
University of Wisconsin, and I am sure similar in your state,
as a major academic center where we have satellite outreach
clinics in community practice settings where we provide the
radiation oncologists and physics technical care and we will
assist them with the billing process in those community
processes.
Mr. CHABOT. Thank you very much.
And I would note, Cincinnati Children's Hospital is usually
in the top three best children's hospitals in the country. And
when you consider the size of Cincinnati versus some other
areas, we are very proud of Cincinnati Children's Hospital. So,
thank you very much.
Chairwoman VELAZQUEZ. The gentleman yields back.
And now we recognize the gentlelady from Kansas, Ms. Davids
for 5 minutes.
Ms. DAVIDS. Thank you, Madam Chair.
I appreciate the opportunity for us to discuss this very
important topic today. I definitely am determined to do
everything I can while during my time here in Congress to
increase patients' access to health care. I am very, very
concerned about the prior authorization and STEP therapy being
used are barriers to that access.
I have heard from a lot of providers in the Kansas Third
District which I represent, providers and physicians, and they
are frustrated. They are disheartened by the way that prior
authorization and STEP therapy are used to delay care. And I
know some similar sentiments have been shared here today.
I was recently able to take a tour of a pediatric
orthopedic practice in Prairie Village, Kansas, and learned
about the burden of STEP therapy in their practice. For that
small business, fighting for a single STEP therapy protocol
exemption or appeal costs their nursing staff sometimes 1 or 2
full hours as different insurance providers use different and
often complex processes. That kind of arduous paperwork just to
provide the right care to patients imposes increased
administrative costs which I am sure you are familiar with. And
just the time to the medical practice.
I guess the first question I would ask is prior
authorization and STEP therapy are intended to be processes
that encourage providers and insurers to seek the most cost-
effective treatments and procedures. Do you think those
processes generally reduce out-of-pocket costs for patients?
And I will just open it up because I am sure everybody on the
panel probably has thoughts on that.
Dr. CULLEN. I do not think that it does. I mean, first off,
I think that if we just had a transparency of what the direct
costs were, the actual costs, that we would more to reduce
costs for our patients than any other factor. Because as family
physicians, that is what we try to do. We try to reduce the
burden for our patients regardless.
What I have seen though is that the costs really have risen
as we have engaged in this whole process of prior authorization
and STEP therapy. And so it really does not seem to be doing
its intended purpose, if that ever was its intended purpose.
But like I said, I think just having a transparency of what
things actually cost is going to do more than anything else.
Mr. ROGERS. From the dermatology perspective, I can tell
you that in many circumstances the cost to the patient is
grossly higher. And I will just use an example of what is
called a topical calcineurin inhibitor, which is a type of
cream that is nonsteroid and has no side effects associated
with the skin. And a lot of insurers are requiring two failures
of steroid medication which may be contraindicated to sensitive
areas like groin, face, things like that, before you can get
coverage of the medication that is going to work with the least
side effects. And so the patient has multiple copays before
they actually get what they need.
Dr. WALEGA. I also think there are cases in which the steps
of the STEP therapy really do not make sense for the patient
and it wastes valuable time and money. I think in cases,
particularly with specialists, I am probably biased, but by the
time the patient gets to a medical specialist, many of the
simple things have failed. And our judgment I think is quite
important, and in some cases we should be deferred to and we
are not.
Ms. DAVIDS. Well, one, I appreciate that and Dr. Cullen, I
would just say I think you hit the nail on the head when you
said if it was the intended purpose.
I will leave it at that. I appreciate your time, your
testimony, and the work that you all are doing.
And with that I yield back.
Chairwoman VELAZQUEZ. The gentlelady yields back.
And now we recognize the gentleman from Minnesota, Mr.
Hagedorn, for 5 minutes.
Mr. HAGEDORN. Thank you, Madam Chair. Thanks to the
witnesses.
I would agree. You go out and do all this education,
training. Put years and years of work to prepare to treat
patients and then you go to do the work and you have to ask
permission every step of the way and people are looking over
your back and questioning you. And then sometimes changing
basic decisions that you make as to how best to treat patients.
And so whatever we can do in order to make it possible for you
to do your job, we will support you 100 percent. We will
support that bill you are talking about with the Safe STEP Act.
And also, but is this not also part of kind of a scam that
is going on with these pharmaceutical benefit manager programs
where you will prescribe a drug and there may be like two
competing drugs do the same thing and when it comes time to
fill it at the pharmacy there are these rebates and things that
they get back the money. It does not go to the patient. It does
not go to the consumer. It certainly does not go to you. And
they are picking winners and losers as to which drugs to use
based on basically kickbacks. They jack up the price of the
drug in many instances in order to make that happen. Are you
familiar with this? Do you see this in your practice? I will
leave it to anybody. You do not have to use my language on it.
I am pretty tough. You know what I am talking about though;
right?
Mr. CULLEN. I think that I am going to defer to your
expertise on this.
Mr. HAGEDORN. Well, we spent some time during the break
with a local pharmacy and they walked us through it. And it is
pretty rough what happens. And it is, again, it is not helping
the consumer and it is not helping the patient, necessarily.
But they are deciding based upon what works best for them
financially which of the drugs to prescribe. And in the olden
days, you know, doctors would talk with pharmaceutical company
owners. Now you cannot have hardly any of those conversations.
You cannot take a pen. They have wiped you out of that, which
is fine, I guess. But there is this kind of middle man that is
doing that job now and I would like to see some of the reforms.
If you do not want to address it, maybe it is too sensitive.
But we will move on from there.
The other thing I would say is this is not just a problem
that you have with private insurance companies; right? Do you
not deal with the government a little bit and have some of the
same issues? Like, there are some things that we can do to
streamline that with Medicare, Medicaid? I will start over
here.
Dr. HARARI. Absolutely. This is pervasive, and I think your
words that this is not benefitting the patient is very
precious. There is no benefit to a cancer patient to have a
delay in the start of their treatment. And even when there is
the intent to be sure that an effective therapy is being
delivered often by pushing the physician to generate a less
expensive therapy that comes with collateral damage in the name
of radiation, we are applying a simple plan to treat a brain
tumor where the beam has to go through the eye and cause damage
to normal tissue or go through the heart to treat a lung cancer
because they want to see a simple, just front and back
radiation rather than a conformal plan. Less expensive but more
damage to the normal tissue for the patient. And so in terms of
cost, ultimately this costs the healthcare house of medicine
much more to deal with those side effects. So this happens on
all sides.
Dr. WALEGA. On a more practical level I know that my
Medicaid patients and the Medicare Advantage patients are
scheduled 15 business days after their evaluation with me when
I have put forth a treatment plan because we know it is going
to take at least that long to get that approved. So 15 business
days is 3 weeks. That is a long time to wait for treatment when
you have pain that is described as 10 out of 10.
Dr. CULLEN. We actually have fewer problems with Medicaid
and Medicare than with a lot of the private insurers. I mean,
this is a process that is going across the board but I guess in
answer to your previous comment, the big problem we are having
is that the formularies are changing on a regular basis and
that is because of things other than patient care. And so that
is something that we are dealing with. It is creating just
tremendous chaos in our ability to prescribe for our patients.
And it is causing chaos for the patients because a lot of times
they have been on medications for years and all of a sudden we
have to come up with something else. And even if we change the
dosage, we have to come up with another prior authorization
plan. This has absolutely gotten out of control. So in light of
that, actually, the Medicaid and Medicare are actually doing
better than the others.
Mr. ROGERS. Congressman, I agree with you entirely in that
government plans are a problem in addition to private insurers.
At least in my state, the kind of most egregious delays in care
and not getting back to our office of whether a prescription is
approved or denied is frequently seen with the state Medicaid.
Mr. HAGEDORN. Thank you very much.
Chair, thank you.
Chairwoman VELAZQUEZ. The gentleman yields back.
And now we recognize the gentleman from Pennsylvania, Vice
Chair of the Committee, Mr. Evans.
Mr. EVANS. Thank you, Madam Chair. I thank you, Madam
Chair, and the Ranking Member for this hearing. This is very
appropriate during this time.
Dr. Cullen, according to your testimony, primary care
physicians spend nearly 50 percent of their time on
administrative activities, such as prior authorization and only
20 percent of their time on clinical activities. Do these
burdensome tasks limit the number of patients primary care
physicians can accept and treat?
Dr. CULLEN. Indeed. So I have been in practice for 25
years. Before all this started I would see about 25 patients a
day. I am now down to about 15 patients a day. So this has
reduced the number of patients that I have been seeing. That is
a problem because we are looking at a severe shortage of
primary care physicians in this country, and what I am
experiencing is being replicated across the country.
Mr. EVANS. Can you explain the role in that particular case
of primary care or family physicians in the patient's overall
health care?
Dr. CULLEN. So one of the reasons why our healthcare system
is as expensive as it is, is that we do not prioritize primary
care to the extent that we should. We are spending about 4
percent of our dollars on primary care. Other healthcare
systems that are spending a lot less money on health care than
we are have upwards of 15 to 20 percent of their dollars spent
on primary care. The problem is, is that things that are not
caught in a timely fashion or the chronic diseases that end up
in hospitalizations, if we do not have family physicians and
primary care physicians managing those, you end up spending a
lot more money. So for every dollar spent on especially
advanced primary care, you save about $13 overall to the
healthcare system as a whole.
One of the reasons why we are spending as much as we are,
18 percent of our GDP on health care is because we are not
prioritizing primary care.
Mr. EVANS. Can anyone else on the panel, that same question
I asked, explain the role of primary care family physicians and
patient, give some reaction to that? Any other comments on
that?
Yes?
Mr. ROGERS. I agree with the incredible importance of
having ready access to primary care with a huge variety of
different treatments that they can do in disease processes. As
a small specialist, I also see the value of specialty care in
that there are more advances in medicine every year than has
ever been in the past of medicine. And so in order to provide
patients with the most up-to-date care, we need an integrated
system that allows primary and specialty care to interact and
collaborate efficiently.
Dr. WALEGA. I would also add that we have discussed the
shortage of primary care physicians. That trend is continuing.
When medical students finish medical school and they go through
their training, they often have $100,000, $200,000, $300,000
worth of debt. I cannot imagine that one would be able to pay
off that debt in a timely way if you are seeing 12 to 15
patients a day in a family practice. It just does not make any
economic sense at all. So that trend will continue.
Dr. HARARI. There is a reason that many of the U.S. medical
schools are emphasizing primary care to their medical students.
At the University of Wisconsin, we are one of two schools of
medicine and public health that is trying to serve the needs of
the state in rural areas of Wisconsin. Many states have this
issue where the cities are well served with primary care but
the rural communities are not. And so as Dr. Cullen alluded to,
we have to make a much more concerted effort to provide
talented primary care providers to our citizens.
Mr. EVANS. Madam Chair, I yield back the balance of my
time.
Chairwoman VELAZQUEZ. The gentleman yields back.
And now we recognize the gentleman from Pennsylvania, Dr.
Joyce, Ranking Member of the Subcommittee on Rural Development,
Agriculture, Entrepreneurship, and Trade for 5 minutes.
Mr. JOYCE. Thank you, Madam Chairwoman.
Today, I have with me a letter signed by 371 national and
state-based patient, provider, and other healthcare stakeholder
groups in support of H.R. 3107, the Improving Seniors Timely
Access to Care Act, which would bring the needed transparency
and accountability to prior authorization in the Medicare
Advantage Program. I respectfully ask that the letter be
submitted for the record.
Chairwoman VELAZQUEZ. Without objection, so ordered.
Mr. JOYCE. Thank you, Madam Chair.
First of all, I look out at this esteemed group, and with
bias I say it is the most intelligent group that has presented
to our Committee so far.
Mr. CHABOT. We have got a lot of intelligent people here.
Mr. JOYCE. Thank you, Ranking Member Mr. Chabot.
I have worked closely with radiation oncologists, I have
friends, I have utilized anesthesiologists with backgrounds in
pain management. And daily, until just 8 months ago, I would
interact with family practitioners who are the heart and soul
of American medical care. And of course, when I look at Dr.
Rogers, I see a compadre, a board-certified dermatologist, a
fellow in the American Academy of Dermatology. We share so
much. I hear your story and I thank each and every one of you
for bringing it to the halls of Congress. It is so important
for us to realize what you go through on a daily basis for as
you said, Dr. Cullen, to make people's lives better. It seems
like a simple goal. And yet there are obstacles that are being
placed in front of you. And we need to hear and work hard to
repair those obstacles that are in front of you.
So please allow me, if I can address the first question to
Dr. Rogers for being here today.
Dr. Rogers has an interesting expertise that I would like
to illuminate and tell everyone on the Committee what he does.
He is a board-certified dermatologist, as he said, that takes
care of over 3,000 diseases, skin diseases, and diseases that
affect all organ systems in the body. In addition to that, he
did additional training in Cincinnati with Dr. Brett Coldiron
in Mohs micrographic surgery which is a long name for a type of
surgical training that allows the dermatologist to remove the
skin cancer and see that the margins are clear and then repair
it. So it seems like a simple process. He talked about treating
a patient with a skin cancer on their nose and arduously he
removed that skin cancer until there was no sign of it left
behind and then he went to repair that and he could not have
the authorization to do that repair. This is a tragedy. This
does not allow for good patient care.
So what does that mean? That means that the patient is
going to have to come back, risk adverse reactions, the
collapse of the cartilage of their nose while he waits for the
approval to do that, and go through anesthesia again. Go
through the injections that he has already put the patient
through and is prepared to repair that.
Dr. Rogers, did I summarize this case clearly?
Mr. ROGERS. You did. Thank you, Congressman. You did
summarize that well.
As a dermatologic surgeon, it is clear to us that as we are
working on the patient, there are a lot of patient-specific
factors. We cannot know exactly how best to repair somebody
from a functional standpoint so that they are going to breathe,
have normal lip function, have normal eyelid function, as well
as a great cosmetic result beforehand, which is basically what
the insurer is asking for. They are asking for a prior
authorization exactly how this is going to go. And when you are
in the operating room, you do not know until you are there and
then you are scrambling to try to get prior authorization to do
a medically necessary procedure to put this patient back
together.
Mr. JOYCE. In other areas, let's talk general dermatology
if I may, please.
Someone comes into your office. They have a cellulitis, a
skin infection of the upper extremity. And let's say from our
common knowledge base that you prescribe a form of penicillin,
maybe a cephalosporin that has been in the generic form since I
graduated from medical school, from a long time ago. And you
want to prescribe Cephalexin. What obstacles are placed in
front of you, Dr. Rogers?
Mr. ROGERS. Yeah. So this has actually become a problem
this year which is just kind of unimaginable. So the main
standard of care treatment for a staph infection, superficial
staph infection, is oral Cephalexin. We all know if you have a
staph infection you have got to jump on it right away. And
there is an insurer who has placed a prior authorization on
Cephalexin, and I have seen two instances in my office where
superficial infections have gotten out of control because of a
prior authorization process that delayed treatment. The patient
went to the pharmacy, did not get their medicine, and then
progressed rapidly and had to be hospitalized resulting in
hundreds of thousands of dollars of expense that could have
been dealt with right at the pharmacy.
Chairwoman VELAZQUEZ. The gentleman's time has expired.
I now recognize the gentlelady from Minnesota, Ms. Craig,
for 5 minutes.
Ms. CRAIG. Thank you so much, Madam Chairwoman.
I just want to start by saying I had an ear infection last
week and I went to see my primary care physician and I got an
earful pretty much in addition to treatment for that ear
infection on exactly what each of you have testified this
morning. So thank you so much for being here.
Health care is absolutely the number one issue that I hear
about in my congressional district. My colleague from Minnesota
just a moment ago talked about the cost of prescription drugs.
My own experience in health care has been that when we have
these conversations it is a little bit like the circling firing
squad. Brand name pharmaceuticals blame the PBMs. PBMs blame
the pharmaceutical companies. And everybody blames the health
insurance companies.
I am curious as we sit here today on a couple of issues
though. Where do you think each of you, as members of Congress,
we can beyond just the administrative burden which is
absolutely clear is an issue in our country, where else would
you have those of us who just arrived in Congress focus in
terms of the cost of health care? Not just the cost of health
insurance but the cost of health care?
And I was particularly curious, Dr. Cullen, your comments
around prevention over care. And then I want to ask the
specialists a couple of questions, too.
Dr. CULLEN. So a lot of it I think has to do with access.
And how much people are paying out of pocket, which is
definitely getting worse.
I had a patient recently who did not come in to be seen for
an ear infection because of her copay. As a result she
developed just a rip-roaring otitis externa that I ended up
having to put her in the hospital for. So what would have been
a $65 visit and a $25 prescription of an antibiotic turned into
probably a $15,000 to $20,000 hospitalization. We are doing
this repeatedly where we are saving money up front and we are
paying so much more down the road. And that is not only true
with just the cost. I mean, there is a human cost, too,
because, for example, maternal mortality has increased and part
of that has to do with the access for prenatal care which is
diminishing and we are having obstetrical deserts develop in
the country. Access is probably one of our biggest things.
Because we do not have that access, and I would include the
access to a primary care physician, that we are spending
enormous amounts of money at the other end where we could be
spending a little bit in the beginning and we could be
recouping that investment enormously at the other end. I think
that is probably the biggest issue outside of the amount of
administrative work.
Right now we are spending, yes, it is two for one, 2 hours
of administrative time for every hour of patient care. If we
cut that in half we could see twice as many patients. I mean,
this is something we definitely need to address.
Ms. CRAIG. I also just want to follow up with that with Dr.
Harari.
Tell me, is there any reason in your mind to justify prior
authorization for CT scans when dealing with routine cancer
care? It is interesting to me that that is even a barrier for
you.
Dr. HARARI. It is interesting to us as well. I recognize
that in the broad scale of medicine, imaging can benefit from
care and judicious allocation of resources. But when a patient
has a cancer diagnosis and they need to have high quality
imaging, be that a PET scan or a CT scan to best, most
accurately define their tumor so that a surgery or radiation or
chemotherapy can be most effectively delivered, it is
unfortunate sometimes to have so much second guessing of the
known cancer expertise on what that imaging should be.
Ms. CRAIG. And where would you have us focus on driving
down the cost of health care?
Dr. HARARI. You mentioned, the others have mentioned the
issue of prevention. Cancer prevention is an enormous area of
potential benefit. The funding of the National Cancer Institute
and the NIH in advancing prevention studies, the known role of
tobacco and alcohol and nutritional elements that contribute to
cancer, we could diminish the cancer burden in the U.S.
dramatically with some steps in those areas as opposed to
waiting until there is an advanced cancer present.
Ms. CRAIG. Thank you.
Madam Chair, I am just about out of time, so I will yield
back.
Chairwoman VELAZQUEZ. The gentlelady yields back.
And now we recognize the gentleman from Oklahoma, Mr. Hern,
Ranking Member of the Subcommittee on Economic Growth, Tax, and
Capital Access for 5 minutes.
Mr. HERN. Thank you, Madam Chairwoman, Ranking Member, and
certainly to the docs that are here to testify on real problems
in medicine today.
Like my colleague said, no matter where you go, you do not
have to be a doctor, you can be a patient. If they know you are
in Congress, you are going to hear the issues. And so it is
great to hear it firsthand.
I have been a businessman for 34 years, and what we know is
regulations cause problems. Certainly, when you have extraneous
regulations like you all are experiencing, it is very
difficult. In my world, it is Dodd-Frank and many other
regulations that cause a real burden on the small business. We
have heard these from many times over and people sitting in
your same position. As the Ranking Member said, we have had a
lot of really smart people talking about regulation, regulatory
problems across many industries.
You know, in the small business practices, your hurdles
really are about utilization management programs that are all
sizes that really create a real problem. It could be as much as
pharmaceutical companies advertising on TV a better drug than
you prescribe. And the patient saying I want that drug because
I saw an advertisement. We have a whole plethora of issues that
we need to get after in this realm. As my colleague once again
said, this is one of the number one issues, if not the number
one issue in America today to figure this out.
Fortunately for me personally, I have a colleague that is a
dear, dear friend of mine that you have already heard from that
I want to yield the balance of my time. I am a person that says
instead of some of us that just talk about and use talking
points, let's let folks who are really experts in this field,
and I want to yield the balance of my time to Dr. Joyce,
please.
Mr. JOYCE. Thank you, Representative Hern. And thank you,
Madam Chair, for allowing me just to complete this.
I think the message that you brought to us today is clear.
That STEP therapies and authorizations delay care. So I am
going to allow Dr. Rogers just to kind of shine the light on
what you mentioned briefly. But I am going to lay some
background.
So he talked about treating some serious skin conditions
and the ability to make a decision not to use topical steroids,
which have severe side effects in some situations of where you
apply them. So you might not want to put a topical steroid on
your face because it thins the skin. And there are other areas
of the body that you might choose to use a prescription Vitamin
D analog. He mentioned it by its name.
And yet, Dr. Rogers, I am going to turn it back to you with
the remaining time. So I send to you a 12-year-old with a type
of dermatitis, an inflation of the skin that you make a
decision to use a nonsteroid, a topical therapy that has very
few side effects to the skin that is a Vitamin D analog. What
challenges do you face?
Mr. ROGERS. So for dermatology, pediatric patients are,
they are special. They have a very high amount of surface area
of skin, and so you always have to worry about side effects and
absorption in those patients. And so you do not necessarily go
through the standard way of thinking about patients. You start
with safety first because that is how I would deal with my own
children.
And so when I see a patient like this, first of all, I know
that I am in for a long, lengthy battle. It is not the old days
where you write a prescription, send them to the pharmacy, and
they get what you prescribe and get better. So I come out of
the exam room and I say, all right, we are going to start this
Vitamin D analog. Could you start the process? And so the
prescription gets entered and the pharmacy then gets a denial.
And then they send back a number for us to call of the pharmacy
benefit manager that is associated with this insurance. And
then my staff spends an hour on the phone to figure out what
clinical information it is that they want. Then we get some
forms, fill those out, send it back. Then, they send it back
saying denied. You need to go through STEP therapy. I write an
appeal letter saying this is a 12-year-old boy. I do not want
to be placing a high-potency topical steroids that are going to
result in side effects in this patient. It is not standard of
care. They delay for 2 weeks and then it results in a denial. I
write another appeal letter and get a peer-to-peer which may or
may not go through. The whole process took me an hour and it
took my staff 4 hours for this denial. And the frustration
level is quite extreme.
Mr. JOYCE. And in the meantime, the patient care is
delayed; is that true?
Mr. ROGERS. Delayed and the patient continues to suffer
needlessly.
Mr. JOYCE. I think that you have all come to us to shine a
light on this problem, and I thank my colleague for the
additional time.
Madam Chair, I yield back.
Chairwoman VELAZQUEZ. Thank you. The gentleman yields back.
Now we recognize the gentleman from Illinois, Mr.
Schneider, for 5 minutes.
Mr. SCHNEIDER. Thank you, Madam Chairman. And I want to
thank the witnesses.
I apologize. We are oftentimes pulled in different
directions, so I am just getting here. But I had a chance to
read through your testimonies, so I appreciate you sharing your
experiences.
Dr. Walega, I will start with you. Also from Chicago. Been
a patient at Northwestern. A fan of Northwestern. Graduate of
Northwestern.
But in your testimony you described the testimony of a 38-
year-old patient who goes through a process. You do the first
step of the test to make sure the treatment works and then you
have to go through the delays. And I read that story with
empathy, frustrations. You can run through the list of
emotions.
What would the right process look like if you were just to
describe it? What are the goals that we should we working to
achieve in putting guardrails on the system but making sure
that you are able to do what you want to do and that the
patient is able to get, in this case, the woman is able to get
the treatment that she deserves?
Dr. WALEGA. So I know the case was fairly extreme but I
actually experience these same similar stories every day.
I think the main point of this case was a tremendous delay
between when we found a proven therapy that improved profoundly
this patient's quality of life, her family's quality of life
beyond expectations, 8-1/2 months later requiring, you know,
going back on opioids, I think everyone in this room has been
concerned about the opioid crisis. The pendulum is swinging on
opioid prescribing. We do not ever want to put a patient back
on opioids if we found something better, more effective, that
can be used for the patient's entire life. A shorter period
between the time of the proposed therapy and the actual
approval. We need to have a specialist who is similarly trained
or experienced to help make the decision whether the treatment
that we are proposing is medically necessary. Our role should
not be to educate someone who knows absolutely nothing about
the therapy or the disease process. That individual should not
be in charge of deciding the patient's healthcare fate.
Mr. SCHNEIDER. And to that point, Dr. Harari, and I may be
repeating myself of things said earlier, but in your written
testimony you talked about the times that you are talking to
someone who is not a peer-to-peer review. And you know, if you
can elaborate on that. Is it absolutely necessary to have
someone who is a peer or just have someone who understand what
you are talking about? Is that trainable?
Dr. HARARI. Thank you, Congressman. Ultimately, we want to
have someone who has the best interest of cancer patients in
mind. And repeatedly, it is apparent that that is not
necessarily the case when we are going through the prior
authorization process. There does appear to be a repeated
denial and delay strategy knowing that some practitioners,
particularly small, private community practitioners who do not
have the bandwidth to hire personnel to combat the paperwork
with prior authorization. We have had ASTRO members recount
stories where they say I will go ahead and deliver the slightly
less optimal radiation treatment plan knowing that then I will
not have to go through a 5-hour process or recreate multiple
treatment plans that are going to be denied. So ultimately,
that is hurting cancer patient outcome and ultimately adding
cost to the system.
Mr. SCHNEIDER. Okay. And my last question I will ask the
whole panel and start with you, Dr. Rogers and go across.
I understand the problems with process, and I come to this
as an industrial engineer, process engineer, process matters.
What about the goals of trying to make sure, not just that we
are getting the right care but the right cost? Is there a
problem with the goals at the very beginning or is this
strictly the process?
Mr. ROGERS. In a time of increasing healthcare
expenditures, of course the goal has to be to deliver cost-
effective, high-quality care. Having a prior authorization
process that is efficient, transparent, and workable for a
small business practice would meet that goal plus the goals of
running a small business.
Mr. SCHNEIDER. Dr. Cullen?
Dr. CULLEN. And I would agree with the goal is we want high
quality but a less costly system than we have currently.
As far as the process, we have all gone through training
for many, many years and I think that one of the frustrations
about this is the not trusting us to use our best judgment
based on our education and based on our experience. We could
save enormous amounts of money by just not engaging in all this
activity. So I think we need to minimize the prior
authorization process as much as possible.
So I have two people that are doing full time. They are
doing prior authorization. They could be better served taking
care of patients, doing prevention, doing education. Instead,
all of our resources are really devoted to something that we
have the training just to take care of.
Mr. SCHNEIDER. And I am out of time.
Chairwoman VELAZQUEZ. The gentleman's time has expired.
Mr. SCHNEIDER. I yield back.
Chairwoman VELAZQUEZ. Now we recognize the gentleman from
Ohio, Mr. Balderson, for 5 minutes, who is the Ranking Member
of the Subcommittee on Innovation and Workforce Development.
Mr. BALDERSON. Thank you, Madam Chair. And thank you all,
panel. I appreciate you all taking the time to be here today.
I am going to be very brief. I know that everybody has been
here for quite some time. But last year, physicians,
pharmacists, medical groups, hospitals, and health insurance
announced their commitment to working together to improve prior
authorization process for patients' medical treatments. I have
a consensus here, and I would like to put this in the record,
please, that was done by many member organizations that most of
you are associated with. And if you do not know what this is, I
can most certainly give it to you. We can send you guys a copy
so you can go over this. AMA authorized it. Blue Cross Blue
Shield, American Hospital Association, amongst some of the few.
But in it, the healthcare leaders stated their intent to
work together to streamline requirements for therapies, as well
as accelerate industry adoption of national electronic
standards for prior authorization.
What other actions could be taken to improve the challenges
faced by healthcare professionals? And anybody on the panel can
answer the question.
Dr. Harari?
Dr. HARARI. Thank you, Congressman, for bringing that
forward. And the comment, there are a lot of elements of the
prior authorization that could be streamlined and improved.
There are centers of excellence in terms of quality and value
that are having 90 percent of their denied prior authorizations
overturned on appeal. Those centers could be identified to say
there is no practice challenge here. We could spot check 1 in
10 cases for prior authorization rather than torture them
through every case. There are a variety of examples like that.
Increased transparency, publication, public dissemination of
the utilization parameters that each insurance provider uses so
that it is not a mystery to the patient and to the provider as
to which regulations they are using. Often, they are not using
national standards. In oncology, National Comprehensive Cancer
Network, 30 of the top cancer centers in the Nation that create
guidelines, many of these third-party benefit manager
organizations do not even adhere to those national benchmarks.
So there are a number of areas of transparency that could be
improved.
Mr. BALDERSON. Thank you. That was a great answer.
Would anybody else like to comment?
Doctor Rogers, I apologize.
Mr. ROGERS. Thank you very much for that excellent
question.
One of the things that comes to me that could definitely
improve the situation from a transparency standpoint and also
from a consistency standpoint would be to have, instead of
pharmacy benefit managers deciding on how best to administer
prior authorizations, have the physicians who are at the point
of the spear weigh in. You know, the American Academy of
Dermatology would love to have a seat at the table in terms of
defining what is reasonable in terms of different treatment
algorithms and would have much greater buy-in from our
physicians if we could have that sort of collaborative
arrangement.
Mr. BALDERSON. We are dealing with PPMs in the state of
Ohio I am sure you have heard.
Dr. CULLEN. So I think, I told the story earlier that I had
to prior authorize hydrochlorothiazide which is a generic
medication. I think that all generics should not have to go
through the prior authorization process. I think that is just
absolutely ridiculous. And so I think that as much as we can
minimize that prior authorization I think is really important.
As physicians, we really do try to do the right thing by
our patients and we are spending a lot of money just because
there are a few outliers. And I think that all of us are trying
to do the very best we can for our patients for the least
amount of cost. And I think there needs to be some recognition
that that is what we are trying to do. Part of the problem with
prior authorization is assuming that physicians are only in it
for other reasons and that is just not the way it really is.
And so I think that I would like to see all of that whole
process minimized.
For those practices that are involved in quality-based
payment contracts, there is really no reason to have prior
authorization at all. And that is with alternative payment
methodologies. Not fee-for-service. We were actually getting
paid by the quality we deliver. And so there should be no prior
authorization for those practices.
Mr. BALDERSON. Would you like to add or do you think that
everybody has fulfilled the----
Thank you very much. And I appreciate it.
I yield back, Madam Chair.
Chairwoman VELAZQUEZ. The gentleman yields back.
Let me take this opportunity again to thank all of the
witnesses for taking time out of their schedule to be here with
us today.
As we have heard today, our country's healthcare providers
want nothing more than to provide their patients with the
highest quality and clinically appropriate care. However, time
and time again, delays in treatment are leading to adverse
outcomes by taking doctors away from patient care. We need to
improve the prior authorization process by streamlining and
standardizing some of the procedures, while also making sure
there is a clear understanding by doctors and patients of the
items and services subject to prior authorization.
I look forward to working with my colleagues on both sides
of the aisle on this important issue. And believe me, this is a
committee that works in a bipartisan way.
I ask unanimous consent that members have 5 legislative
days to submit statements and supporting materials for the
record.
Without objection, so ordered.
If there is no further business to come before the
committee, we are adjourned. Thank you.
[Whereupon, at 12:59 p.m., the Committee was adjourned.]
A P P E N D I X
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]