Congress should advance pro-patient policies that enhance provider decision making

At the beginning of the 118th Congress, a looming health care policy question was whether a divided government could open a window for an incremental, bipartisan, commonsense health care policy to emerge. While we must wait to see, what we do know is there is a consensus in Washington that many of the problems we face today are not going away on their own.

For example, last year, it looked like in an end-of-year package, Congress might take action to delay the 4.5 percent Medicare payment cut for physicians. If it had gone through, there would have been recognition of the severe impact that these across-the-board payment cuts would have on providers struggling with surging medical inflation, increased labor costs, and the shift to value-based care — but instead of addressing the need for financial stability and predictability, we saw some cuts implemented and the rest merely postponed.

For specialists like me, Medicare physician payment cuts further compound other headwinds we face. Rheumatologists, who treat rheumatic diseases like arthritis which is the primary cause of disability in this country, confront a myriad of unique challenges from insurance companies to provide patients access to innovative therapies, most notably biologics, immunotherapies, and even lower-cost biosimilars. Unfortunately, insurance company practices often inhibit our patients’ timely access to care, creating unnecessary delays to needed treatments and services.

However, I remain hopeful that bipartisan coalitions can emerge in a divided Congress to prioritize a patient-first agenda. The following policy changes would go a long way to help reduce access barriers that work against standards of care, best practices, and patient health.

First, it is time to reform prior authorization—the often lengthy process of securing approval from payers for specific therapies or procedures before physicians can treat their patients. This process increases the time patients must wait before receiving the care they need and puts their health condition on hold. It also monopolizes physicians’ administrative time to fill out forms and appeal denials — adding to physician burnout.

Last Congress, the Improving Seniors’ Timely Access to Care Act made it through the House but died in the Senate. It is time to take up this effort again, as this bill would help modernize and streamline some prior authorization processes in the popular Medicare Advantage program. Legislators should also follow Rep. Buddy Carter’s (R-Ga.) lead as he continues to spotlight abuses by pharmacy benefit managers (PBMs) that contribute to the higher costs patients pay for their prescriptions. Sen. Maria Cantwell’s (D-Wash.) PBM Transparency Act (S.127) is also a good start to bring accountability to drug price negotiations.

Step therapy—in which insurers require prescribing cheaper medications first before stepping up to more expensive versions—is also in desperate need of reform. These kinds of fail-first policies, included in employer-sponsored health care plans, are solely based on cost and serve to delay patient access to effective therapies. Just as alarming, these policies put insurance companies—not practicing physicians—in charge of making critical decisions that impact patient access and outcomes. Congress should pass The Safe Step Act (S.652) which would place reasonable limits on the use of step therapy and help to clarify the process for patients.

Finally, it is beyond time for Congress to address the use of co-pay accumulators, which insurance companies leverage to profit from the cost-sharing assistance patients receive from drug manufacturers. Ultimately, this practice shifts the costs of specialty medications onto patients themselves. Congress can address this issue through legislation by requiring health plans to count the value of co-pay assistance toward patient cost-sharing requirements. That would help ensure that all payments, whether made by patients directly or via the help of drug manufacturers’ co-pay assistance, count toward the out-of-pocket cost calculation under their plan.

These reforms would benefit patient health and quality of life while helping physicians—who work at the epicenter of patient-centered care—better mitigate the increasingly high barriers to access created by the soaring costs of novel therapies.

For decades, we have faced an all-out assault of market and policy pressures that undermine physician decision-making authority, taking that ability away from qualified providers and giving it to insurers. In a divided Congress, a bipartisan group of lawmakers has the power to level the playing field and advance pro-patient policies rather than those that only serve to increase payer profits, undermine physicians’ ability to provide high-quality health care and create new access barriers for patients.

Christina D. Downey, MD, is Associate Professor of Medicine, Division of Rheumatology at Loma Linda University Health. The opinions expressed are her own and she does not speak on behalf of her employer.