ACR Urges CMS to Address Step-Therapy Policies

14/03/2023

New rules to streamline prior authorization in public health insurance programs should address step-therapy policies and require a 24-hour approval process for urgent requests, according to new comments by the American College of Rheumatology (ACR).

The comments, issued March 13, were in response to a proposed rule by the Centers for Medicare & Medicaid Services (CMS) aimed at reducing the burden of prior authorization policies and improve patient access to health information.

“Theoretically, prior authorizations enhance evidence-based practices to ensure proper treatment without unnecessary costs,” wrote ACR President Douglas White, MD, PhD, in the organization’s comment letter. “Sadly, prior authorizations have become a way to hinder, deter, or prevent the services and treatments that allow providers to treat their patients effectively.”

According to a survey released by the American Medical Association — also published on March 13 — 94% of physicians reported that prior authorization policies delayed access to necessary care, and 89% said that these policies negatively affected patient outcomes. One third of respondents reported that prior authorization policies ultimately led to a serious adverse event for a patient, including hospitalization, permanent impairment, and even death.

In the comment letter, the ACR provided several recommendations to further alleviate the impact of prior authorization restrictions on care:

Expand guidance to include “all utilization management tools for services and therapeutics, including step-therapy policies.”
Issue additional sub-regulatory guidance on step-therapy policies to improve patient access to necessary therapies.
Shorten the timeline for urgent requests from 72 to 24 hours. For nonurgent requests, a 7-day approval deadline is appropriate.
Keep the proposed requirement that payers provide a reason for denying prior authorization requests.
Exclude e-prior authorization measures under the performance improvement category until electronic medical records can report these data without causing additional work for clinicians.

“Prior authorizations put an undue burden on providers seeking to do what is in the best interests of their patients,” said Dr White said in an ACR press release. “The ACR appreciates the consideration that went into this comprehensive rule, and we look forward to working with CMS to implement policies related to improving the prior authorization process.”

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