To: The Honorable Christina Henderson, Chair, DC Council Committee on Health

Members of the Committee on Health

From: Patricia Quinn, VP of Policy and Partnerships, DC Primary Care Association

Re: B25-0124 Prior Authorization Reform Amendment Act of 2023

Date: May 24, 2023

The DC Primary Care Association (DCPCA) works to build a healthier DC by sustaining community health centers, transforming care delivery, and advancing racial and health equity. Our collaborators in this work include community health centers, serving almost 200,000 patients in every ward of the city. Our members serve District residents most impacted by inequity—95% of health center patients are racial or ethnic minority, 88% have incomes below 200% of the federal poverty level, and 37% are best served in a language other than English. We appreciate the opportunity to provide testimony in support of B25-0124, the Prior Authorization Reform Amendment Act of 2023.

DCPCA applauds the efforts to improve patient care and patient experience by improving the process for prior authorization (PA) through B25-0124. The District should join the 40 other states that have requirements regarding how payers can apply prior authorization. Provisions in the Council legislation that make PA valid for a minimum of one year, and that make PA valid for the length of treatment for chronic or long-term conditions will minimize provider and patient burdens, increase patients’ ability to follow treatment recommendations, and lead to better health outcomes. Requirements for timely action and notification on PA requests, and qualification standards for those making PA decisions are important improvements that will increase effectiveness of the health system. Mandating consultation between treating providers and utilization review entities when medical necessity is in question will increase provision of patient-centered care and collaboration.

Clear language that the cost of a health care service alone cannot be grounds for requiring PA sends a strong message about the limits of prior authorization employed for cost containment. The continuity of care provisions will ensure that patients will not abruptly lose access to their doctor-directed treatment.

DCPCA supports provisions that prohibit prior authorization requirements for medication-assisted-treatment (MAT) for opioid use disorders. We need to eliminate barriers that delay access to lifesaving MAT amid an escalating overdose crisis. Similarly, our members express frustration in regard to frequent changes to formularies for diabetes medications (insulin) and lack of access to combination pills that simplify medication regimes for patients on multiple medications. More than 15,000 health center patients have diabetes, and 36% of those patients have diabetes that is poorly controlled. The District needs to consider, particularly for Medicaid beneficiaries, how to limit formulary changes that impact access and outcomes.

“With transitions in Medicaid MCOs, coverage for OTC meds changed quite a bit, many things that were covered before are not covered now. Continuous Glucose Monitors are difficult to get covered for patients.”

A key challenge in the “solvable problems” category is to standardize PA forms and align Medicaid MCOs on the same electronic platform. Variation in PA requirements among payers and lack of transparency in medical necessity criteria create administrative burden that can lead to delays in care. Providers reference administrative complexity within a web of different PA requirements.

I wish that all MCOs got on the same page. Some use Covermymeds, others don’t, and rely on fax and paper forms. Others use Surescripts. It is confusing and time-consuming.

Massachusetts has legislation that directs the Division of Insurance to create standardized forms for services requiring PA. The forms cannot exceed two pages of questions assessing medical necessity criteria and once approved by the DOI, must be used and accepted by all payers and providers.

The resources required to administer PA are significant. According to a 2021 survey administered by the American Medical Association (AMA), 40% of physicians reported that they have staff members dedicated solely to processing PA requests. One physician estimates that even the most straightforward prior authorization request takes 30-60 minutes of their time. That is time away from direct patient care in a critically understaffed primary care system.

“This kind of work is also notorious for contributing to physician burnout which causes primary care docs to leave clinical medicine... For this kind of straightforward prior auth I have actually never had one denied – which begs the question of why insurance companies create these bureaucratic hurdles if the end result is that they will approve the prescribed medication.”

We should work collaboratively to identify services with high approval rates and eliminate PA requirements for those services.

DCPCA thanks the Council for its attention to how to improve prior authorization processes. We welcome the opportunity to work with health system stakeholders and with the Council to align PA best practices, standardize administrative forms and systems, decrease burdens on providers and patients, and ensure high-quality health care across the District.