Senator takes aim at prior auths, ‘number one administrative burden to physicians’

Sen. Roger "Doc" Marshall, MD (R-Kansas)

The latest version of the Improving Seniors’ Timely Access to Care Act prompted praise from lawmakers and supporters of physicians and patients when it was reintroduced on June 12.

Sen. Roger “Doc” Marshall, MD (R-Kansas), and his staff supplied a summary of what the bill would do within Medicare Advantage (MA):

• Establish an electronic prior authorization (e-PA) process for MA plans including a standardization for transactions and clinical attachments.
• Increase transparency around MA prior authorization requirements and its use.
• Clarify the authority of the U.S. Centers for Medicare & Medicaid Services to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
• Expand beneficiary protections to improve enrollee experiences and outcomes.
• Require the U.S. Department of Health and Human Services and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

Marshall has been a staunch advocate of reforming prior authorizations for years, and numerous other legislators and medical organizations have voiced their support. He spoke with Medical Economics about it and another bill, the Bipartisan Primary Care and Health Workforce Act, that he is sponsoring with Sen. Bernie Sanders (I-Vermont) to enhance primary care across the nation. That bill has the approval of the Senate Committee on Health, Education, Labor, and Pensions, but has not reached the floor for a full vote in either chamber.

This transcript has been edited for length and clarity.

Medical Economics: You are a leading sponsor of the Improving Seniors’ Timely Access to Care Act. For those not familiar with it, can you explain that legislation?

Sen. Roger “Doc” Marshall, MD: Maybe your listeners have heard of something called prior authorization. So, this is the number one administrative burden to physicians. It was something that impacted my practice. But as the number of Medicare Advantage patients has grown, it's now something insurance companies used to ration care. So, for the senior citizens on a Medicare Advantage program, if they needed their hip replaced, what the insurance companies are doing is using this prior authorization process to delay their surgery. They're making the doctors fax in form after form after form. And what our bill does is, it creates a streamlined process that the insurance companies could have the doctors follow, so every time I'm doing a hip replacement with this particular insurance company, I would know very clearly what they would want to have done, we would send it to them, and we can get that hip replaced and get you back on your feet sooner than you can think.

Medical Economics: Earlier versions of the Improving Seniors Timely Access to Care Act had widespread medical support and bipartisan political support. Why has it taken so long for Congress to pass this?

Sen. Roger “Doc” Marshall, MD: That's a great question, and I wish I could give you a great answer. I think, number one, is it was going to cost some money, at least, that's what the CBO (Congressional Budget Office) report said. I never agreed with that, but the White House has essentially implemented this program for the most part. This would codify it, and therefore, it lowers the CBO score. So, some Washington, D.C., talk that just goes a little bit deep, but the CBO was scoring it as a cost, and we've got that down to zero now.

Medical Economics: Can you discuss the bipartisan primary care and health workforce act? What would that bill do? And what is the status of that legislation?

Sen. Roger “Doc” Marshall, MD: I would love to discuss it. This is something that Senator Sanders, Bernie Sanders and I work so hard on together. You know, Bernie and I may not agree on some things, but we both agree that there is a challenge right now with access to meaningful, affordable primary care. What we see as being a success out there are our community health centers. We have 32 of these across the state of Kansas, introducing primary care, but it also adds things like dentists, mental health, those types of things as well. We're bringing in food nutrition programs as well. So, we're trying to beef those up, so to speak. So we have increased funding for our community health centers. But in addition to that, another thing Bernie and I agree on is we don't have enough nurses out there. There was nothing more important to me in my practice than nurses. Nurses solve the world problems, but we don't have enough of them. So we have increased funding for folks going to nursing school, and not just the students, but also the teachers. What we've heard over and over out there is there wasn't enough funding to get teachers to give up that day job or the night job and do some teaching as well. We also have increased funding for primary care doctor residency programs like family practice internal medicine, so increased funding for those as well. So really trying to address some of the challenges we see out there with primary care. I think that this is absolutely win-win legislation. I think it will actually save money in the long run. If we know anything is when people get primary care on a regular basis, they can prevent some of those really expensive emergency room visits as well as hospital admissions.

Medical Economics: Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know?

Sen. Roger “Doc” Marshall, MD: Wow. I understand the burden on primary care doctors. I was one. I lived that life. I was on call every day, every other day, for some 30 years. So, thank you. I want to start by saying thank you. You are in the trenches, and I know there's, for a whole host of reasons, doctors, especially primary care, doctors, are retiring sooner. They're leaving their careers. They're feeling the pressure. And I just want you to know you're not alone, that I'm personally grateful. I'm disappointed that Medicare has decided to cut your reimbursement. We've done everything we can up here, that doctors were the only ones that are being cut this time around. We've done everything possible to stop that cut. This is the thanks we get for throwing our lives in the fire during COVID. We went to the emergency rooms, we went to the ICUs, we saved lives, and then Congress responds by cutting your pay for Medicare patients. Meanwhile, everyone else is being made whole, all the other folks in the health care food chain, but doctors are left out in the cold. And I just would encourage you to reach out to your congressman, to reach out to your senator, and say, why are you cutting our pay? Just ask them, invite them to come to your office, invite them to come to your hospital, just to see what you're doing, and ask them why they're cutting your pay.