Proposed Medicare Advantage and Part D Changes Aim to Improve Prior Authorization Process, Health Equity

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ACP supports many of the proposed changes for 2024, says they will improve beneficiary protections, boost access to care and promote health equity

March 10, 2023 (ACP) — As the federal government prepares to make major changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit (Part D) programs, the American College of Physicians is urging officials to follow through on plans to improve the prior authorization process and boost efforts to improve health equity.

ACP believes that regulations proposed by the Centers for Medicare & Medicaid Services will make a big difference once approved. “If finalized, revisions to streamline prior authorization requirements will address concerns long raised by ACP about how they have a negative effect on beneficiary access to care,” said Dejaih Johnson, JD, MPA, ACP governmental affairs and public policy associate. “The proposed changes would also improve beneficiary protections, boost access to care — including to behavioral health services — and promote equity in coverage and care.”

The proposed regulations are hugely important because they affect so many people, Johnson said. “Medicare Advantage continues to increase year over year and now serves 30 million people across the country. Forty-nine million of the sixty-five million people enrolled by Medicare are also enrolled in Part D plans,” she noted.

ACP has continually advocated for relieving prior authorization requirements that impose a burden on physicians and patients. Under the proposed rules, MA organizations will be required to establish a Utilization Management Committee to review prior authorization utilization requirements.

“We encourage CMS to revise its proposed policy to put a greater degree of separation between the committee members and the MA organization itself,” Johnson said. “It remains important that, if finalized, there is adequate enforcement to ensure that MA organizations comply with requirements to protect beneficiaries and increase transparency into what is now a manual, highly burdensome, imprecise and costly process. Maintaining the integrity of the process is important.”

On other fronts, ACP supports the efforts to require MA organizations to develop and maintain procedures to offer digital health education to improve access to covered telehealth benefits. “Studies demonstrate that low digital health literacy, especially among populations experiencing health disparities, continues to impede access and worsen care gaps,” explained Johnson.

In addition, ACP supports requirements for MA organizations to incorporate activities that reduce disparities in health care into their quality improvement program. “Examples of these activities include developing and using linguistically and culturally appropriate materials and hiring bilingual staff,” Johnson said. “There also exist stark disparities in accessing behavioral health services.”

ACP commends CMS for continuing to emphasize the role that access to behavioral health plays in whole-person care and the need to address the national mental health and substance abuse crisis. “Through our work to better integrate behavioral and mental health into primary care practice, the College has continued to engage with the agency, as well as congressional leaders, to strengthen behavioral health network adequacy,” Johnson said.

ACP also supports efforts to incentivize MA and Part D plans to improve care for enrollees with social risk factors, such as those who are dual-eligible, receive low-income subsidies or are disabled. “We believe this has the potential to address social drivers of health and drive health equity. We are also encouraged by proposed changes to the Medication Therapy Management eligibility criteria that will require Part D sponsors to include all core chronic diseases in their targeting criteria,” Johnson said. “These proposed changes support the College and CMS's aligned commitment to expanding prescription drug access and affordability.”

In addition, ACP supports a CMS proposal to allow for the removal and substitution of certain prescription drugs from Part D formularies in limited circumstances. “To counteract rising prescription drug spending, ACP supports efforts by Medicare Part D to promote the use of generic prescription drugs and biosimilars, provided therapeutic safety and equivalency are established,” Dr. William Fox, chair of the ACP Medical Practice and Quality Committee, wrote in a Feb. 13 letter to Chiquita Brooks La-Sure, CMS administrator. “CMS's proposal has potential to constrain prescription drug spending while promoting maximal patient access to critical, life-saving treatments.”

The final rule is likely to be published in the spring, Johnson said, and many of the updates and improvements made to the Part D program will go into effect or be in effect on Jan. 1, 2024. “ACP is always appreciative of the opportunity to provide comments on particular updates or improvements where the agency requests feedback,” she said. “As the agency moves through rulemaking, the College welcomes additional opportunities to inform CMS policymaking in these expanding programs.”

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