Model Letter

Model Letter / en Sat, 26 Apr 2025 01:24:23 -0500 Wed, 20 Nov 24 12:36:54 -0600 AHA, Others Support Bipartisan Physician and Health Care Workforce Legislation /model-letter/2024-11-20-aha-others-support-bipartisan-physician-and-health-care-workforce-legislation November 20, 2024<table><tbody><tr><td>The Honorable Mike Johnson Speaker United States House of Representatives Washington D.C., 20515</td><td>The Honorable Hakeem Jeffries Minority Leader United States House of Representatives Washington D.C., 20515</td></tr><tr><td>The Honorable Chuck Schumer &nbsp; &nbsp;&nbsp; Majority Leader United States Senate Washington D.C., 20510</td><td>The Honorable Mitch McConnell Minority Leader United States Senate Washington D.C., 20510</td></tr></tbody></table>Dear Speaker Johnson, Majority Leader Schumer, Minority Leader McConell, and Minority Leader Jeffries:&nbsp;On behalf of the 38 undersigned organizations, we are writing to strongly support inclusion of the bipartisan Conrad State 30 and Physician Access Reauthorization Act (H.R. 4942/S. 665) and Healthcare Workforce Resilience Act (H.R. 6025/S. 3211) in the end-of-year package.The shortage of physicians in this country is growing more urgent each year. Over 80 million Americans live in areas that lack access to a primary care physician, and disparities across health specialties also continue to grow. For example, one-third of Black Americans live in areas that lack sufficient access to a cardiologist. We are committed to promoting access to preventive medicine that keeps patients healthy and able to manage their health conditions. Unfortunately, without sufficient access today, more Americans will face worse health outcomes because they lack access to health care in their communities.By 2036, the United States will face a shortage of up to 86,000 physicians. In that same time, there will be significant growth in the number of Americans aged 65 and older who will need more health care and access to more types of physicians. The growing demands on health care systems require Congress to take steps to prepare to meet the needs of all patients. We continue to advocate for increasing the number of graduate medical education slots, minimizing administrative burdens on physicians and practices, and recognizing the vital role international medical graduates play in our health care system.A growing number of physicians are nearing the traditional retirement age or will over the next decade. While investments in GME will help to mitigate some physician shortages, it could take up to 15 years before a physician is educated, trained, and seeing patients. As a result, increasing the total number of Medicare supported GME slots cannot be the only solution to addressing shortages, particularly in underserved areas.That is why we support strengthening the Conrad 30 waiver program. For 30 years, the Conrad 30 waiver program has incentivized approximately 20,000 highly skilled physicians to practice medicine in rural and underserved areas. A key part of the success of the current program is its flexible design that allows each state to customize how it allocates its 30 waivers to respond to its unique needs.Without a Conrad 30 waiver, IMG physicians on a J-1 visa are required to return to their country of origin for at least two years before applying for another visa or green card. In exchange for the waiver, they must practice in a federally designated underserved area for at least three years.Reauthorizing this program would provide critical updates to the program. In addition to gradually increasing the number of available waivers per state if certain thresholds are met, it would clarify and improve the waiver process for IMGs and employers by expanding the timeframe between when individual receives a waiver and when they must begin work to allow for time to complete their medical education and receive employment authorization.These overdue changes will make it easier for employers to recruit and retain physicians who are practicing in underserved areas. It also clarifies the incentives for physicians to pursue a waiver, who would better understand the waiver process and employment obligations.The Healthcare Workforce Resilience Act would initiate a one-time recapture of up to 40,000 unused employment-based visas – 25,000 for foreign-born nurses and 15,000 for foreign-born physicians – so they can strengthen and provide stability to the U.S. health care system. This legislation would allow for thousands of international physicians who are currently working in this country on temporary visas with approved immigrant petitions to adjust their status. This crucial policy change, which concludes three years after the date of enactment, will enable these physicians to continue serving patients ensuring every American can access needed care.Foreign-born physicians are an invaluable component of the U.S. health care system, comprising nearly 1 in 5 of active U.S. physicians. H-1B physicians practicing vital specialties like geriatric medicine and nephrology also make up approximately 50 percent of active physicians. These realities should compel Congress to immediately take steps to address health workforce shortages and strengthen the highly successful Conrad 30 program that has incentivized U.S.-trained foreign physicians to rural and underserved areas for 30 years.Thank you for your consideration. If you have any questions, please contact Kelly McCone with the American Academy of Neurology at <a href="mailto:kmccone@aan.com" target="_blank">kmccone@aan.com</a> or Eli Greenspan with Physicians for American Healthcare Access (PAHA) at <a href="mailto:egreenspan@foleyhoag.com" target="_blank">egreenspan@foleyhoag.com</a>.Sincerely,&nbsp; Alliance for Headache Disorders Advocacy&nbsp; ALS Association&nbsp; Ambulatory Surgery Center Association&nbsp; American Academy of Family Physicians&nbsp; American Academy of Neurology&nbsp; American Academy of Physical Medicine and Rehabilitation&nbsp; American Association of International Healthcare Recruitment&nbsp; American Association of Neuromuscular &amp; Electrodiagnostic Medicine&nbsp; American Brain Coalition&nbsp; American College of Obstetricians and Gynecologists&nbsp; American College of Physicians&nbsp; American College of Radiology&nbsp; American Gastroenterological Association&nbsp; American Headache Society&nbsp; �� Association&nbsp; American Medical Association&nbsp; American Psychiatric Association&nbsp; American Society of Neuroradiology&nbsp; Anxiety and Depression Association of America&nbsp; Association for Advancing Physician and Provider Recruitment&nbsp; Association of University Professors of Neurology&nbsp; College of American Pathologists&nbsp; Economic Innovation Group&nbsp; Federation of ��s&nbsp; Hydrocephalus Association&nbsp; International Bipolar Foundation&nbsp; International Medical Graduate Taskforce&nbsp; M-CM Network&nbsp; Miles for Migraine&nbsp; MLD Foundation&nbsp; National Ataxia Foundation&nbsp; Niskanen Center&nbsp; North American Neuro-Ophthalmology Society (NANOS)&nbsp; Physicians for American Healthcare Access (PAHA)&nbsp; Premier Inc.&nbsp; Society of Hospital Medicine&nbsp; SynGAP Research Fund, DBA curesyngap1&nbsp; The Society of Thoracic Surgeons &nbsp; Wed, 20 Nov 2024 12:36:54 -0600 Model Letter Model Letter Re: Proposed Rule for Policy and Technical Changes to Medicare Advantage Program in CY 2024 /model-letter/2023-02-06-model-letter-cy-2024-policy-and-technical-changes-medicare-advantage-and-medicare-prescription-drug-0 Download the model letter below.&nbsp; &nbsp; Mon, 06 Feb 2023 15:34:51 -0600 Model Letter AHA to CMS Re: Inpatient Rehabilitation Facility PPS for FY 2023 and Updates to the IRF Quality Reporting Program /2022-05-31-aha-cms-re-inpatient-rehabilitation-facility-pps-fy-2023-and-updates-irf-quality-0 The Honorable Chiquita Brooks-LaSure Administrator Centers for Medicare &amp; Medicaid Services Submitted electronically Re: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2023 and Updates to the IRF Quality Reporting Program. Dear Administrator Brooks-LaSure: On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 900 inpatient rehabilitation facilities (IRF), and our clinician partners — more than 270,000 affiliated physicians, two million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to address the FY 2023 IRF prospective payment system (PPS) proposed rule. The AHA appreciates CMS’s streamlined proposed rule, which helps IRFs and their partners in surging areas continue to focus on their local COVID-19 responses. In addition, we continue to appreciate the IRF-related waivers implemented by CMS, which help optimize the field’s contribution to the national response, both in communities still experiencing surges, as well as for higher-acuity patients recovering from the virus who require both hospital-level care and intensive rehabilitation to address longer-term clinical after effects. <h2>Proposed FY 2023 Payment Update Warrants Closer Examination</h2> For FY 2023, CMS is proposing a net increase in IRF PPS payments of 2.0% ($170 million), relative to FY 2022. This includes a 3.2% market-basket update offset by a statutorily-mandated cut of 0.4 percentage points for productivity, and a 0.8 percentage point cut related to high-cost outlier payments. We note that the proposed IRF PPS labor-related share would only modestly shift upward from 72.9% in FY 2022 to 73.2% in FY 2022. AHA is concerned that these changes neither align with feedback from our members regarding massive cost growth in recent months and years, nor with the findings of recent AHA-commissioned research. Specifically, an April 2022 <a href="/costsofcaring" target="_blank">report</a> by the AHA highlights the significant growth during the COVID-19 public health emergency (PHE) in hospital expenses across labor, drugs, and supplies (as shown in the reproduced chart below), as well as the impact that rising inflation is having on hospital prices. The report cites Bureau of Labor Statistics data showing that hospital employment levels have decreased by approximately 100,000 from pre-pandemic levels. At the same time, hospital labor expenses per patient through 2021 were 19.1% higher than pre-pandemic levels in 2019. Because labor costs account for more than 50% of hospitals’ total expenses, such increases have very substantial impacts on a hospital’s total expenses and operating margins. As widely reported, an increased reliance on contract staff, especially contract nurses, who are integral members of the clinical team, has been driving growth in labor expenses; in 2019, hospitals spent a median of 4.7% of their total nurse labor expenses on contract travel nurses, but by January 2022 this figure skyrocketed to a median of 38.6%. As a result of these changes, January 2022 labor expenses per adjusted discharge are 52% higher than the pre-pandemic levels of January 2020. We are deeply concerned about increased costs to hospitals that are not reflected in the market basket adjustment and ask CMS to discuss in the final rule how the agency will account for these increased costs. We also are concerned about the reduction for productivity, and ask CMS in the final rule to further elaborate on the specific productivity gains that are the basis for the proposed 0.4% productivity offset to the market basket, as this does not align with hospitals’ PHE experiences related to actual losses in productivity during the pandemic. <h2>Proposed Permanent Cap on Wage Index Decreases</h2> The AHA supports CMS’s proposal to smooth year-to-year changes in the IRF PPS wage index. Specifically, to mitigate occasional fluctuations in year-to-year wage index changes, CMS proposes a permanent 5.0% cap on any decrease to a provider’s wage index, relative to the prior year, regardless of the circumstances causing the decline. We agree that such a cap would help maintain stability for this payment system, and the others for which CMS also is proposing this cap. While we endorse this proposed policy change, we urge the agency to implement this change in a non-budget-neutral manner. Only then would the proposed cap truly mitigate volatility caused by wage index shifts. <h2>Adjustment for High-cost Outliers</h2> The AHA is concerned about the dramatic scale of the proposed increase in the high-cost outlier threshold – a 37% increase from the FY 2022 threshold – that would significantly decrease the number of cases that qualify for an outlier payment. The agency’s proposed increase from $9,491 in FY 2022 to $13,038 in FY 2023 seeks to align total FY 2023 outlier payments with its target of 3% of total IRF payments. If the agency were to maintain the current threshold, CMS’s analysis of FY 2021 claims projects that outlier payments in FY 2023 would be 3.8% of total payments. This projection was calculated using the same methodology in effect since the FY 2002 implementation of the IRF PPS. CMS’s long-standing goal in maintaining the 3% outlier pool, which is established in regulation only, is to allocate additional resources to high-need, higher-cost patients, without under-funding the remainder of IRF cases. That said, the proposed rule falls short by not explaining the factors driving this significant increase in IRF high-cost outlier payments, and CMS’s projection of the duration of these factors in FY 2023 and beyond. Furthermore, we are highly concerned about the methodology’s reliance on atypical FY 2021 claims. As such, we ask CMS to examine its methodology more closely and consider making temporary changes, as it has done in other payment systems, to help mitigate substantial increases in the outlier thresholds. For example, in the inpatient PPS proposed rule, the agency used slightly older data to calculate the outlier threshold because CMS recognized that using the two most recent years produced abnormal results due to the pandemic. <h2>Proposed Changes Regarding “Teaching IRFs”</h2> AHA supports CMS’s proposals related to protocols for teaching IRFs. First, this rule would update the current policy addressing medical residents (and interns) who are displaced when a teaching IRF closes. Specifically, the rule would alter the status of a relocating resident based on the date that the originating IRF publicly announces its closure (for example, via a press release), rather than the actual closure date, which would mitigate delayed transfers of a displaced resident to a new IRF. In addition, the rule would allow the receiving IRF to increase its FTE resident cap by submitting a letter to its Medicare Administrative Contractor within 60 days after beginning to train the displaced residents. Further, to improve clarity, CMS is proposing to codify and consolidate the definition of the teaching status payment adjustment factor, and explanation of how the factor is calculated, which is used for IRFs that provide graduate medical education. Specifically, CMS would codify in regulation guidelines that currently only are found in the Medicare Claims Processing Manual, Section 100-04, chapter 3, as they were established in FY 2006 final rule and modified in FY 2012 final rule. <h2>Request for Information (RFI) on IRF Transfer Policy</h2> AHA appreciates the opportunity to weigh in on CMS’s call for feedback from the field on whether to incorporate a “discharge to home health” element in the IRF transfer policy in the future, in alignment with inpatient and inpatient psychiatric facility PPS policies. The transfer policy is intended to disincentivize early discharges from IRFs. It currently applies to stays with a less than average length-of-stay for cases with comparable principal and secondary diagnoses, which are transferred directly to another IRF, general acute-care hospital, or nursing home/SNF. The rule cites a December 2021 report by the Department of Health and Human Services Office of the Inspector General report1 that found that this type of IRF transfer policy expansion would generate savings of approximately $1 billion over two years. However, for any future consideration of a possible expansion of the IRF transfer policy, we recommend that CMS first evaluate the accuracy of the existing policy by confirming the reliability of the data currently being used to identify cases for a transfer policy payment reduction. To identify these cases, the policy uses “discharge destination code” data derived from the IRF-patient assessment instrument (PAI). We raise this concern based on an AHA analysis of CY 2021 standard analytic file (SAF) IRF claims that found the IRF-PAI-based discharge data appear to overstate, by 14%, the number of cases that actually are transferred from an IRF to home health. Specifically, as shown in the chart below, we found that 45% of IRF discharges actually receive home health services within three days, based on our claims-based analysis that matched beneficiary service utilization for IRF and then HH care during a single episode of care. However, using the discharge destination code on the CY 2021 SAF claims, we calculated a rate of 59%. Given this material inaccuracy, we urge CMS not to advance an expansion of this policy, as currently designed. Rather, CMS should evaluate whether and how much Medicare is penalizing IRF cases that actually comply with the policy. Any such over-payments should be corrected. Image RFI on IRF PPS Facility Level Adjustments. While the rule proposes to maintain in FY 2023 the current IRF PPS facility-level payment adjustments listed below, CMS is asking for feedback on its methodology used to calculate facility-level adjustment factors and suggestion on possible refinements in the future. IRF PPS facility adjustments have been frozen since 2014 to mitigate the prior year-to-year volatility that persisted even following attempts by the agency to stem this source of instability. In general, the IRF field has supported this pause. <ul> <li>Rural adjustment: 14.9%</li> <li>Low-income patient adjustment factor: 0.3177</li> <li>Teaching facility adjustment factor: 1.0163</li> </ul> The adjustments provide an increase in per-case payments based on an IRF’s rural status, percentage of low-income patients, and teaching status to account for differences in costs attributable to these characteristics. Prior annual updates were made in a budget-neutral manner, and any future changes also likely would be budget neutral. While CMS is not proposing a change for FY 2023, the rule highlights what the annual facility adjustments would have been for FY 2015 through FY 2023, including substantial volatility. In other words, CMS’s freeze of the facility adjustments has helped increase payment predictability and stability for the field. Moving forward, we support CMS’s ongoing pursuit of a remedy to, absent the current freeze, mitigate the volatility that persists. In particular, we highlight members’ concerns with the accuracy of the teaching adjustment, and ask CMS to evaluate its reliability and impact, perhaps using the comparable inpatient PPS policy as a benchmark. <h2>QUALITY REPORTING-RELATED PROPOSALS</h2> <h3>IRF Quality Reporting Program (IRF QRP)</h3> The Affordable Care Act mandated that reporting of quality measures for IRFs begin no later than FY 2014. Failure to comply with IRF QRP requirements results in a 2.0 percentage point reduction to the IRF’s annual market-basket update. For FY 2022, CMS requires the reporting of 18 quality measures by IRFs. CMS does not propose to adopt any new quality measures or standardized patient assessment data elements (SPADEs) in this rule. The agency does propose to require IRFs to report quality data on all patients, regardless of whether they are Medicare beneficiaries. CMS also solicits comments on potential future measures for inclusion in the IRF QRP as well as on how the agency can leverage its programs to advance health equity. Collection of Quality Data Regardless of Payer. Beginning Oct. 1, 2023, IRFs would be required to collect the IRF Patient Assessment Instrument (PAI) upon admission and discharge for each patient. CMS made the same proposal in the FY 2020 IRF PPS proposed rule, but did not finalize the proposal in response to several logistical questions raised in comments as well as assertions that the expansion and accompanying implementation timeline would be overly burdensome, especially considering the addition of several SPADEs to the IRF-PAI. While CMS purports to have addressed these questions and assuaged these concerns, the AHA does not believe the information supporting this proposal bears this out. CMS argues that because providers currently report quality data on all patients in the Long-term Care Hospital (QRP) and the Hospice QRP, it is not unreasonable to expect IRF providers to do the same. The experiences of LTCHs and Hospices are not comparable to IRFs. According to MedPAC’s March 2021 Report to Congress, there were approximately 162,500 LTCH stays in 2019; in comparison, and according to the same report, there were over 705,000 IRF stays in the same year. These vast differences in volumes demonstrate that expanding data collection for non-Medicare patients (who make up about 44% of those stays) is a significantly larger undertaking for IRFs than for LTCHs. Hospices currently do not administer a patient assessment in the same way as IRFs administer the PAI, but a comparable process is one by which hospices abstract data from medical records via a standardized tool called the Hospice Item Set (HIS). The HIS is 10 pages long; the IRF-PAI is 30. Again, the collection of data upon admission and discharge for additional patients in the hospice setting is not a comparable task in an IRF. By CMS’s own calculations, each additional IRF-PAI would take 1.8 more hours of clinical staff time. The IRF workforce is already overburdened by administrative requirements, and as CMS adds more and more SPADEs to the IRF-PAI, there is less and less time for patient care. In addition, as approximately 44% of IRF patients are covered by commercial insurers, CMS should ensure that the assessment processes used for these payers are aligned with those informing the IRF-PAI so as not to introduce additional or conflicting processes. Because of the substantial increase in burden associated with this proposal, the AHA suggests that CMS extend the timeline for the implementation of this requirement until at least Oct. 1, 2024 to give providers time to prepare. RFI on Health Equity. Continuing its efforts to determine how the agency can leverage its data collection and quality reporting capabilities to address disparities in health outcomes, CMS discusses a general framework that could be used across CMS quality programs to assess disparities through data reporting. CMS describes options to assess drivers of health care quality disparities within the IRF QRP specifically. One option to do this would be to employ performance disparity decomposition, which allows one to estimate the extent to which differences in measure performance between subgroups of patient populations are due to specific factors. Another way to determine disparities within the IRF QRP could be to adopt measures related to health equity. Here CMS describes the Health Equity Summary Score, a measure developed for Medicare Advantage plans that computes disparities in performance on measures across different subgroups as well as among different plans. The AHA applauds CMS’s commitment to addressing disparities in health outcomes by considering creative approaches for data collection and manipulation. We agree that it is our responsibility as health care providers to improve outcomes for all our patients, but we cannot hope to affect real change without high-quality data and analysis. That said, the concept of an aggregated quality score proffered in this rule would not be a helpful step in achieving these goals, and we recommend CMS focus its efforts elsewhere. Quality of care is complex, and outcomes are driven by a plethora of factors both within and outside of the providers’ control. Social risk factors, too, are deeply personal and historical facets of society, which manifest in nuanced and intricate ways that are difficult to capture accurately. Thus, it is hard to imagine feasibly calculating a single score that aggregates and averages performance on multiple measures across patients who identify with various subgroups of the population; it is even harder to imagine that such a score would provide useful information for either providers to use to pinpoint gaps and develop solutions to address them or consumers to use to inform decisions about where to get care. At best, a summary score assessing performance in health equity would be ineffective, since a score like the Health Equity Summary Score merges performance for disparate groups (i.e., performance is calculated by “rolling up” scores for racial and ethnic subgroups along with those for beneficiaries who are eligible for both Medicare and Medicaid). By conflating performance on so many factors for many different kinds of patients, a summary score would actually blind consumers to how well a provider actually cared for a person demonstrating certain social risk factors. At worst, a publicly displayed summary score could mislead consumers and providers by making grand, overarching assertions about performance on addressing disparities that contradict true quality of care. Poor performance for patients in certain subgroups would be averaged with high performance for others, resulting in middling scores allowing at-risk patient groups to slip through the cracks. CMS offers multiple ideas in the RFIs for how it could use its tools to help providers address disparities in health outcomes. The most promising, stratifying performance on quality measures by race and ethnicity and dual eligibility in confidential feedback reports, is the exact opposite of the summary score. To optimize the ease-of-use of quality performance data, enhance public transparency of equity results, and build towards provider accountability for health equity, we urge CMS to focus on strategies to improve the consistency of collected data and capabilities to analyze that data rather than blurring important details with a summary score. Thank you for the opportunity to comment on this proposed rule. Please contact me if you have questions or feel free to have a member of your team contact Rochelle Archuleta, AHA’s director of policy, at <a href="mailto:mailto:rarchuleta@aha.org">rarchuleta@aha.org</a>, on any payment-related issues, and Caitlin Gillooley, AHA’s director of policy, at <a href="mailto:cgillooley@aha.org">cgillooley@aha.org</a>, regarding any quality-related questions. Sincerely, /s/ Stacey Hughes Executive Vice President for Government Relations and Public Policy �� Association Tue, 31 May 2022 13:41:34 -0500 Model Letter Model Letter on Medicare Advantage RFI on Prior Authorization for Hospital Transfers The Centers for Medicare &amp; Medicaid Services (CMS) Jan. 12 released a proposed rule for the Medicare Advantage program, which includes a request for information (RFI) on prior authorization for hospital transfers to post-acute care settings during a public health emergency. The AHA has developed a model comment letter that hospitals and health systems can use to assist with submitting their own comments in response to the RFI. <a href="/system/files/media/file/2022/02/220218-Model-Letter-on-Medicare-Advantage-RFI-on-Prior-Authorization-during-PHE.docx">Download the model letter .docx file here.</a> Please note that there are opportunities in the model letter for you to add your own information about how the regulations would affect your organization. <hr /> (Insert Date) The Honorable Chiquita Brooks-LaSure Administrator Centers for Medicare &amp; Medicaid Services 7500 Security Blvd Baltimore, MD 21244 Re: Request for Information: Prior Authorization for Hospital Transfers to Post-Acute Care Settings during a PHE (CMS 4192-P, Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program) Dear Administrator Brooks-LaSure: On behalf of [name of hospital or health system], we appreciate the opportunity to comment on prior authorization requirements for patient discharges to post-acute care (PAC) settings and the significant challenges these policies have raised for our organization and the patients we serve, especially during the COVID-19 pandemic. We encourage the Centers for Medicare &amp; Medicaid Services (CMS), working with Congress as necessary, to require plans to waive these administrative processes during public health emergencies (PHEs). [Provide detail about your hospital or health system, such as the role hospital/health system plays in the community; descriptive characteristics, such as size (patients served), type (rural, urban, DSH, academic medical center, one of the community’s largest employers, etc.); and region. Additional detail on the effects of the COVID-19 pandemic also may be helpful (patient surges, labor shortages, financial impact of pandemic, etc.).] In order to best care for our community during the COVID-19 pandemic, we needed to quickly turn over general acute-care hospital beds and create space for higher-need COVID-19 patients, as well as ensure access to the appropriate level of care for those recovering from the virus. This necessitated urgent modifications to traditional discharge processes and clinical pathways to optimize personnel, physical plant and other resources. The flexibilities offered by CMS to relax or waive prior authorization requirements for Medicare Advantage (MA) plans were invaluable for general acute-care hospitals in implementing these modifications. However, a substantial limitation of this flexibility is that it encouraged, but did not mandate, that MA plans waive such processes. While many MA plans worked collaboratively with provider partners to waive or relax onerous prior authorization requirements during the PHE, others did not, or only did so during the initial stages. The continued use of prior authorization and other health plan utilization management policies by some plans throughout the pandemic has prevented referring hospitals from utilizing desperately needed health system capacity in PAC settings. This has been especially problematic when general acute-care beds have been filled to capacity and while hospitals contend with the demands of vaccine distribution and workforce shortages. It also can have unintended consequences for patients who are then forced to stay in acute care settings unnecessarily while waiting for health plan administrative processes to authorize the next steps of their care. Even today, these challenges persist. [Provide detail about your hospital/health system experience working with health plans on waiving/relaxing prior authorization or other utilization management policies during the PHE. For example: <ul> <li>Detail problems with the process of requesting a waiver from health plans and the associated administrative burden (including the time from request to approval of waiver)</li> <li>Cite the number of health plans that were unresponsive to requests for waivers of requirements</li> <li>Include average turnaround time for prior authorization approval during the PHE for plans that did not approve waivers</li> <li>Estimate how many patients were affected by prior authorization or utilization management policies at your facility or system during the PHE</li> <li>Estimate the number of excess hospital days due to inability to transfer patients</li> <li>Cite specific examples of consequences associated with delayed patient transfers to PAC settings]</li> </ul> We recognize that prior authorization is a tool that, when used appropriately, can help align patients’ care with their health plan benefit structure and facilitate compliance with clinical best practices. However, its misuse and application during a PHE has caused a number of specific challenges that have negatively affected patient care and health system capacity during a global health crisis, which we discuss in more detail below. Continued flexibility and adoption of prior authorization waivers by MA plans would materially improve pandemic responses across the country. Unwarranted Prior Authorization Delays Harm Patient Care. It is clear that keeping patients in the emergency department or an inpatient bed while waiting for the health plan’s decision or response to a prior authorization request is not in the best interest of the patient. These delays often result in missed clinical opportunities for patients to access the more-specialized care typically provided in PAC settings. This is a clear detriment for patients with or recovering from COVID-19 whose condition requires interdisciplinary and targeted PAC care that combines medical care and rehabilitation. This is particularly important for high-complexity patients and those experiencing cases of “long-COVID-19.” Such delays due to prior authorization requirements also can interfere with patients’ prescribed PAC plan of care, which is established by the referring hospital’s treating physician and clinical team, and is intended to help patients return to their home or community sooner. When patients are delayed from being transferred to more appropriate clinical settings that focus on both medical and rehabilitative needs, their PAC plan of care cannot be implemented as intended, and progress toward their recovery is often negatively affected. [Insert data on average turnaround time for PA (e.g. delays in transfers) or examples of patients waiting in inpatient beds while awaiting plan decision, etc.] These concerns are consistent with the findings of a September 2018 report by the Department of Health and Human Services Office of Inspector General (OIG), which warned that high rates of MA health plan payment denials and prior authorization delays could negatively impact patient access to care.<a href="#fn1">1</a> Further, a 2021 survey by the American Medical Association of more than 1,000 physicians underscores the negative impact on patient care resulting from prior authorization. The survey found that more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care. Also, more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care, and more than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers.<a href="#fn2">2</a> General Acute-Care Hospitals’ PHE Capacity Needs to Be Augmented by PAC. During the pandemic, some general acute-care hospital patients could wholly or in part receive clinically-appropriate care in another setting, such as a long-term care hospital, inpatient rehabilitation facility or skilled nursing facility. However, prior authorization requirements frequently delayed or prevented discharge in these cases, requiring general acute care hospitals to allocate clinical resources to manage patients who could otherwise be safely discharged. Utilization of PAC settings is a critical component of the health system’s necessary response to a PHE, and health plan administrative processes should not supersede the imperative to free up general acute-care hospital capacity and facilitate patient transfers to other settings where clinically appropriate. Further, from a PAC perspective, there are widely-held concerns about the behavior of MA plans who approve prior authorization requests for PAC, but later issue retrospective denials for the same services. This has been a long-standing and problematic issue for many PAC providers and the resulting hesitancy also contributed to delays in patient transfers from general acute-care hospitals to PAC facilities during the PHE. Health Plans’ Adding Administrative Burden to the National PHE Response. Many MA plans use inconsistent administrative protocols and a dizzying array of timelines and requirements for prior authorization requests, reviews, approvals and communication, which are unnecessary at best, but rise to the level of unconscionable during a PHE. Excessive requirements and variation between them adds burden to the system as providers and their staff must ensure they are following the right set of rules and processes for each plan, which may change from one request to the next, and can also vary by plan, product and vendor. Despite the tremendous time and resources needed to comply with such extensive requirements, prior authorization requests are often returned multiple times to provide additional information and are further delayed by slow health plan responses, which typically do not occur outside traditional business hours. During a time of national emergency where workforce shortages and strained health system capacity have been persistent challenges, there is simply insufficient bandwidth to comply with such cumbersome administrative procedures. Prior authorization processes also have exacerbated workforce challenges and contributed to physician and other staff burnout during the PHE. Hospitals often have multiple full-time employees whose sole role is to manage health plan prior authorization requests. These staff often are physicians and nurses who have been diverted from patient care. Part of the challenge stems from health plans’ use of peer-to-peer calls to establish prior authorization for a service or treatment without providing access to clinicians with the right type of expertise. Physicians report that their offices spend on average two business days of the week dealing with prior authorization requests, with 88% rating the burden level as high or extremely high.<a href="#fn3">3</a> [Insert hospital/health system example, including the staff time (# of FTEs or hours) or cost incurred to comply with health plan requirements.] Lack of Transparency of Clinical Guidelines. Health plans commonly use medical necessity criteria and other clinical guidelines for general acute-care hospital and PAC admissions, which differ by plan and deviate from those used by fee-for-service (FFS) Medicare. These modifications often are deemed proprietary and not shared with providers, resulting in a black box methodology for determining whether a service is medically necessary. As a result, it becomes nearly impossible for providers to anticipate what the health plan might request as evidence of medical necessity pursuant to a criteria that they will not share. As a result of this lack of transparency in clinical guidelines, there is often extensive back and forth between providers and health plans in response to insurer requests for excessive amounts of documentation to substantiate the need for particular services. It is not uncommon for health plans to request information that is not directly relevant to making a determination about whether post-acute care is needed (e.g., when evaluating a prior authorization request for rehabilitation services, requesting information on a medication that would not impact the need for rehabilitation services). Further, with regard to transitions to PAC, many plans apply their medical necessity criteria based on the subjective judgment of clinicians with limited or no knowledge of PAC. [Insert example of hospital/health system experience with documentation requests and peer-to-peer consults, especially when the plan physician does not have relevant knowledge/expertise.] Overuse of Prior Authorization. Some health plans require prior authorization even for services where there is no evidence of abuse and for which the standards of care are well established. [Insert example from your hospital/health system; it could include examples of services where prior authorization is required even though the service is not new, costly or frequently misused; example of a case where the need for prior authorization delayed critically time sensitive care or medication.] Specifically for PAC services, health plans frequently deny the presence of medical necessity for services that are supported by the literature and that are covered by FFS Medicare. For example, despite clear clinical guidelines directing providers to place certain medically-complex stroke patients in inpatient rehabilitation facilities for a combination of medical and intensive rehabilitation services, health plans commonly require prior authorization or even deny this service. OIG Found Unwarranted MA Denials. The majority of the prior authorization and coverage denials are for covered, medically necessary services that are rejected for administrative processing reasons as opposed to concerns about the legitimacy or appropriateness of the service. Generally in these cases, clinicians treat patients using their best medical judgment, but too often their expert opinion is overridden by the plan (and often by a clinician without relevant expertise in the particular specialty or PAC discipline). Ultimately, many of these denials are overturned through time-consuming administrative appeals. The September 2018 OIG report referenced earlier found that among appealed cases, MA plans overturned 75% of their own denials between 2014-2016 (approximately 216,000 denials per year) through their own appeals processes.<a href="#fn4">4</a> These findings highlight a pattern of health plans inappropriately denying access to services and payment that should have been provided. [Insert example of health plans denials for services that were clearly medically necessary.] Thank you for your attention to these issues. Urgent and continued action is needed to ensure that health plans’ administrative processes do not impede patients’ ability to receive timely, quality, medically necessary care in clinically appropriate downstream settings. This is more important than ever as we continue into our third year of a global pandemic, fighting new variants and surges, administering additional vaccine doses, addressing workforce shortages, and maintaining critical testing and treatment capacity. We again urge CMS, working with Congress, to establish the authority to require – not just encourage – health plans to waive these processes during PHEs. [Insert closing and signature.] <hr /> <ol> <li id="fn1">U.S. Department of Health and Human Services, Office of Inspector General (OIG). “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns about Service and Payment Denials.” September 25, 2018. <a href="https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp" target="_blank" title="Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns about Service and Payment Denials.">https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp</a>.</li> <li id="fn2">American Medical Association, “2021 AMA Prior Authorization (PA) Physician Survey.” Accessed at: <a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank" title="2021 AMA Prior Authorization (PA) Physician Survey.">https://www.ama-assn.org/system/files/prior-authorization-survey.pdf</a>.</li> <li id="fn3"><a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank" title="2021 AMA Prior Authorization (PA) Physician Survey.">https://www.ama-assn.org/system/files/prior-authorization-survey.pdf</a>.</li> <li id="fn4"><a href="https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp" target="_blank" title="Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns about Service and Payment Denials.">https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp</a>.</li> </ol> Tue, 22 Feb 2022 08:19:33 -0600 Model Letter