[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


 UTILIZATION MANAGEMENT: BARRIERS TO CARE AND BURDENS ON SMALL MEDICAL 
                               PRACTICES

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                                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                     
          
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                   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

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                     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.]
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