Congress’ prior authorization power play

The ideas and innovators shaping health care

Jun 21, 2023 View in browser   By Ben Leonard and Erin Schumaker WASHINGTON WATCH DelBene and a majority of her colleagues want stricter rules around prior authorization. | Francis Chung/POLITICO Many in Congress think the government needs to set stricter rules to prevent health insurers’ from slow-walking decisions on whether to approve treatments. But representatives hit a snag last year after their bill to tighten up the “prior authorization” process breezed through the House because senators were concerned about the measure’s projected $16 billion cost. So they’re urging the Centers for Medicare and Medicaid Services to use its power over insurers to tighten up the rules around prior authorization. How so? More than 230 representatives and 61 senators wrote today to Health and Human Services Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure asking them to make changes to a rule CMS proposed in December that would require health insurance companies to modernize the way they process treatment-authorization requests from providers. “The proposed CMS rules make huge strides forward for seniors,” Rep. Suzan DelBene (D-Wash.), the lead author of the letter and sponsor of last year's bill, told POLITICO. “But we think it needs to go further.” The lawmakers are calling on CMS to add several provisions to the regulation to align it more with the legislation, including: — Real-time prior authorization for routine matters — A 24-hour deadline for Medicare Advantage plans to answer prior authorization requests for “urgently needed care” — More detailed transparency metrics Why it matters: Insurers require health care providers to get their approval before conducting certain treatments. Their aim is to control costs, but ensuing delays in care can put patients at risk. A lack of standards among insurers can hamper the process. CMS’ December proposal would require Medicare Advantage plans and other public payers, such as those managing state Medicaid plans, to implement an electronic process for approving treatments. The regulation was expected to be less expensive for the government than the legislation the House passed last year. “The CBO score was an unfortunate roadblock last Congress, especially in the Senate. We shouldn’t let a CBO score get in the way of helping seniors access the care they are already entitled to under Medicare,” DelBene told POLITICO. “The hope is that once the rule is finalized and we get quality policy in place, hopefully with the real-time decision-making and faster response deadlines components, it will also bring the score down.” What’s next? CMS has set a December 2025 date for finalizing its rule but says it will publish it sooner if it can.   LISTEN TO POLITICO'S ENERGY PODCAST: Check out our daily five-minute brief on the latest energy and environmental politics and policy news. Don't miss out on the must-know stories, candid insights, and analysis from POLITICO's energy team. Listen today.     WELCOME TO FUTURE PULSE Galway, Ireland | Shawn Zeller Future transplants? Researchers successfully froze five rat kidneys in liquid nitrogen, rewarmed them and transplanted them back into live rats — who survived. While it's a big jump from rats to humans, transplant experts told STAT News they were excited by the results, which were published in Nature Communications. Currently, human organs stored on ice can only be preserved for roughly six to 36 hours, depending on the organ. "If you remove time from [the equation], then all of a sudden things change dramatically," David Klassen, chief medical officer for the United Network for Organ Sharing, told STAT. Today on our Pulse Check podcast, host Megan Messerly talks with Alice Miranda Ollstein about how some groups are employing an unconventional legal tactic in their efforts to dismantle abortion bans — leveraging religious freedom. Listen to today’s Pulse Check podcast CHECKUP A wearable on that wrist could help doctors keep track of the patient's movement, a new study found. | Sean Gallup/Getty Images Wearable devices tracking movement could help providers ensure hospitalized patients are moving enough. That’s according to a new systematic review and meta-analysis published in JAMA Network Open. Why it matters: The inactivity that often accompanies hospitalization can lead to increased frailty and greater likelihood of death, studies have shown. How could wearables help? Australian researchers analyzed 15 studies with a combined 1,911 participants and found a significant association between using wearable devices that track movement and increased levels of physical activity and improved physical function. Wearables “hold promise for improving patient activity and supporting recovery during hospitalization,” the researchers wrote. Even so: The study found no link between the interventions and pain levels, mental health, readmissions and stay length. What’s next? “As health care becomes increasingly digitized, further exploration of the clinical outcomes and cost-effectiveness of [wearables] in different groups who are hospitalized will be crucial for guiding their use and maximizing their potential benefits,” the researchers wrote.   SUBSCRIBE TO POWER SWITCH: The energy landscape is profoundly transforming. Power Switch is a daily newsletter that unlocks the most important stories driving the energy sector and the political forces shaping critical decisions about your energy future, from production to storage, distribution to consumption. Don’t miss out on Power Switch, your guide to the politics of energy transformation in America and around the world. SUBSCRIBE TODAY.     PANDEMIC House Foreign Affairs Chair McCaul is convinced Covid leaked from a lab. | Francis Chung/POLITICO The investigation into Covid’s origins is heating up again on Capitol Hill. Lawmakers are pressing the Biden administration to release government intelligence and also reacting to reports that a Chinese researcher who fell ill with Covid-19-like symptoms in November 2019 had studied coronaviruses with U.S. funding. House Foreign Affairs Committee Chair Michael McCaul (R-Texas) today said he was convinced the pandemic was a result of a lab leak from China’s Wuhan Institute of Virology following a Wall Street Journal story that confirmed reporting on the Substack blog Public about three institute researchers who fell ill just before the pandemic began. The information came from U.S. intelligence reports, the Journal reported. What’s next? Lawmakers may receive confirmation of that when the Biden administration releases its intelligence on Covid’s origins, as Congress mandated in a law President Joe Biden signed in March. The Office of the Director of National Intelligence missed the law’s June 18 deadline to release the data. “It is far past time for President Biden to use all of the tools the U.S. government has to finally confirm Covid-19 leaked from the [Wuhan Institute of Virology] and was allowed to become a global pandemic,” McCaul said in a statement Wednesday. “People – both those in China and those in the U.S. who aided their coverup – must be held responsible,” he said. Even so: Scientists globally have not yet reached a consensus about whether the pandemic started following an accidental lab leak or through a natural spillover of the virus from animals to people, and U.S. agencies are divided on the question.   Follow us on Twitter Ben Leonard @_BenLeonard_ Ruth Reader @RuthReader Carmen Paun @carmenpaun Erin Schumaker @erinlschumaker   Follow us

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