Patients Over Paperwork: Reducing the Burden of Medicare Red Tape

Urologists across the country treat a high volume of Medicare patients and therefore deal with the program’s numerous requirements and complex payment structures on a near daily basis. The AACU is dedicated to working with legislators and policymakers to identify ways to simplify and improve the efficiency of the Medicare program.

The AACU is committed to identifying ways to simplify and improve the efficiency of the Medicare program, and encourages all Congressional members to continue to reach out to the medical community as they contemplate ways to improve care for Medicare beneficiaries.

In an effort to balance the goals of improving patient care with that of reducing administrative burden, the AACU urges lawmakers to work with CMS to address the following concerns.

EHRs are undeniably at the core of successful MACRA participation, and yet, their implementation and use continues to be one of the biggest challenges for urologists as they try to navigate this completely new payment program. One of the biggest obstacles to EHRs is their lack of interoperability; limits of current EHR technology and slow progress made towards system compatibility have made it nearly impossible to quickly and easily exchange protected medical information between EHR systems in order to facilitate coordinated care.
Moreover, the underlying data requirements are not only irrelevant to actual patient care, but they also do little to enhance and promote interoperability. Similarly, the Evaluation and Management documentation guidelines were developed when medical records were paper-based and are now severely outdated, creating voluminous medical records that have become a hindrance to care and communication among physicians.

To address these problems, the AACU urges lawmakers and CMS to implement the following solutions:

✅ Prohibit information-blocking by EHR technology providers and develop interoperability standards for patient data sharing.

✅ Improve underlying data captured in EHRs by encouraging CMS to retool the ACI category in a way that allows physicians to choose the measures that apply to their specific specialty and that are most relevant and useful to their daily practice.

✅ Issue guidelines on privacy and security considerations for interoperability, and update the Evaluation and Management documentation guidelines to reflect the realities of the digital EHR-era.

While prescription drug costs are a major obstacle in providing Medicare patients with the medications they need, that is just the beginning of the struggles faced by urologists. After writing a prescription for their patients based on their medical expertise, physicians are then required to go through multiple dubious steps to ensure that those prescriptions actually get filled and dispensed to the patient, and in some cases, even after going through the process and doing everything required, it still might get denied.

Skyrocketing list prices and increased utilization management requirements can be attributed in large part to pharmacy benefit managers (PBMs), who act as intermediaries between insurers, manufacturers, and pharmacies and thus play a uniquely central role in the prescription drug market, handling everything from negotiating discounts with manufacturers to determining which drugs are covered by which health plans. Unfortunately, there is very little transparency surrounding PBMs and their role within the delivery system, nor are there any requirements to pass negotiated savings and rebates that PBMs receive from manufacturers onto payers or patients. Even further, cost-sharing obligations under Part D for both the government and patients are based off of the unfairly inflated list price, which fails to take into account the manufacturer rebates that are meant to serve as retroactive discounts off the drug price to drive down costs.

The AACU urges lawmakers and CMS to implement the following solutions:

✅ Increase transparency in the system by legislatively mandating that PBMs disclose the rebate amounts received and further regulating PBM practices that exploit the lack of transparency to increase profits at the expense of the patient.

✅ Require plan sponsors to apply at least a minimum percentage of manufacturer rebates and all pharmacy price concessions received for a covered Part D drug in the drug’s negotiated price at the point of sale, which will allow patient cost-sharing to be based off the net price, not the inflated list price.

✅ Restrict or limit the use of utilization management techniques that lead to unnecessary and costly administrative burden on physicians and undermine the patient-physician relationship by interfering in a patient’s treatment course.

Prior authorization is a significant administrative burden for urologists treating Medicare patients in terms of time and practice costs, which greatly outweighs the likely minimal savings generated. Current prior authorization processes are inefficient and non-transparent, making it difficult for physicians to not only navigate but also to understand the rationale for the many requirements and often inconsistent outcomes. In many cases, the lengthy and time-consuming process leads to delayed treatment and puts patients at risk of negative health outcomes.

The AACU urges lawmakers and CMS to reduce the burden of prior authorization by:

✅ Greatly limiting the services and medications subject to prior authorization requirements.

✅ Streamlining the prior authorization process to alleviate administrative burden on physicians, putting time restrictions in place to reduce treatment delays, and making process requirements clear and readily accessible so that they are easy for physicians to understand and follow.

✅ Requiring justification be provided to physicians for each decision made and establish an expedient and simple appeals process to challenge disagreeable outcomes.