Improving Seniors’ Timely Access to Care Act Aims to Improve Prior Authorization Process

Although prioe authorizations can be a valuable tool, they are often a barrier to care for many seniors.¹ They have been identified by health care providers as the primary administrative burden in pharmacy, with nearly 80% of Medicare Advantage enrollees subjected to unnecessary delays as a result of the current prior authorization process.¹

Man looking down at prescription | Image credit: Budimir Jevtic - stock.adobe.com

In 2018, the inspector general at the US Department of Health & Human Services (HHS) conducted an audit and discovered that, after appeal, Medicare Advantage plans fully or partially approved 75% of requests that originally were denied.² This process is an untimely, unnecessary burden on health care professionals, as well as the patients awaiting approval. Significant time is spent forwarding prior authorizations and insurance requests to provide necessary details or justification. Once a decision is communicated, further time is spent documenting the action and notifying the patient when the medication is ready to be picked up. This process means significant time is dedicated to getting the medication approved and into the patient’s hands.¹

In 2018, there were 52.4 million individuals in the United States 65 years or older, making up 15.6% of the population.³ By 2030, it is projected that there will be more individuals in the United States years or older than children younger than 5 years.³ As it currently stands, the health care system may not be equipped to handle this growing older population, in addition to the associated comorbidities and polypharmacy.⁴

Although stereotypes often present older adults as frail, disengaged, and cognitively impaired, many of these patients can be industrious, creative, and intelligent well into their 90s. Supporting these patients and helping them continue to live fully presents unique challenges that the current health care system is not adequately meeting.⁵ Copious amounts of paperwork, untimely delays, and additional hassles lead to delayed care and can cause poorer health outcomes for these individuals.⁵ As pharmacists and health care professionals, our main goals are to optimize health outcomes and streamline patient care, so tackling these barriers is crucial.

In order to help combat many of the issues delaying accessibility to health care services and medications, the Improving Seniors’ Timely Access to Care (ISTATC) Act was introduced to the US Congress early in 2022.¹ This bipartisan legislation would benefit Medicare Advantage beneficiaries by modernizing the current prior authorization process, placing the emphasis back on patient health rather than on paperwork.⁵

The prior authorization process is intended to ensure that patients receive the appropriate treatments and to control the cost of care, but the current system is outdated and not meeting the needs of patients.⁵ By streamlining this process, which involves undue amounts of time and phone calls, the administrative burdens could be reduced and medical interventions could be made faster.⁵ This optimization is beneficial for both the patient and health care provider.

The legislation is multifaceted and aims to improve the overall prior authorization process for Medicare Advantage beneficiaries. A major priority would be to establish an electronic prior authorization process that would reduce the administrative burden placed on health care providers.¹ In addition to this, HHS would be required to implement a new process for real-time decisions for certain routinely approved medical services.⁵ This would greatly improve patient accessibility to many services, reducing the waiting time for prior authorizations and allowing patients to receive care in an expeditious manner. Under this legislation, prior authorizations would be designed to serve older patients first, hopefully further reducing poor health outcomes and their unnecessary delays.¹ The ISTATC Act would also increase transparency in order to improve the communication between Medicare Advantage plans, patients, and health care professionals.¹

The current prior authorization process is cumbersome and creates unnecessary delays that can be harmful to patients.⁵ The aging population in the United States is increasing rapidly, making it even more important for the health care system to adapt to meet older patients’ unique sets of needs.³ The introduction of the ISTATC Act is a step in the right direction. It would reduce administrative burdens and expedite the prior authorization process, hopefully leading to better health outcomes and optimized patient care for members of the aging population.⁵

References

1. Sen. Cramer, colleagues introduce Improving Seniors’ Timely Access to Care Act. News release. Kevin Cramer, U.S. Senator for North Dakota. February 3, 2022. Accessed May 31, 2023. https://www.cramer.senate.gov/news/press-releases/sen-cramer-colleagues-introduce-improving-seniorstimely-access-to-care-act
2. Medicare Advantage appeal outcomes and audit findings raise concerns about service and payment denials. US Department of Health and Human Services. September 2018. Accessed May 31, 2023. https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf
3. Fulmer T, Reuben DB, Auerbach J, Fick DM, Galambos C, Johnson KS. Actualizing better health and health care for older adults. Health Affairs. January 21, 2021. Accessed May 31, 2023. https://www.healtha airs.org/doi/10.1377/hltha.2020.01470
4. Ageing and health. World Health Organization. October 1, 2022. Accessed May 31, 2023. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
5. Seniors health care improvement bill advanced by House Ways & Means Committee. News release. U.S. Congresswoman Suzan DelBene. July 27, 2022. Accessed May 31, 2023. https://delbene.house.gov/news/ documentsingle.aspx?DocumentID=3196