By Madison Mason, Policy Associate
The Centers for Medicare and Medicaid Services (CMS) released a request for information (RFI), seeking stakeholder opinion regarding their Patients over Paperwork initiative. Patients over Paperwork seeks to reduce administrative burden for providers. The National Health Council (NHC) supports policy changes and refinements that reduce the burden patients and providers face in making treatment decisions and helps provide access to care that best aligns with the patient’s health care needs and goals. We also continue to support thoughtful reforms and policy refinements that promote efficiency, reduce paperwork burden, contain costs, and drive higher-quality care for all Americans, particularly those with chronic diseases and disabilities.
The NHC applauds CMS’ beneficiary engagement activities and urges the agency to expand this important work with an eye toward ensuring representativeness of individuals with chronic diseases and disabilities.
The NHC agrees that when providers spend less time on paperwork and more time on the patient-clinician relationship, patients have a greater opportunity for improvement in the health care outcomes that are most important to them. We have supported the goals of the CMS Patients over Paperwork initiative since its 2017 launch, and we urge CMS to:
- Consider expansion of and refinements to its outreach efforts that would improve the “representativeness” of the feedback, particularly with respect to inclusion of subpopulations of patients with chronic conditions and disabilities, and
- Leverage these Patients over Paperwork outreach initiatives to inform decisions and policy refinements under consideration for reducing Medicare costs.
The NHC responded to the following information requests:
1. Improve the accessibility and presentation of CMS requirements for quality requirements for quality reporting, coverage, documentation, or prior authorization.
- Prior authorization and other management tools
The NHC urges CMS to consider the following recommendations to lead to more transparent and consistent utilization management processes by reducing the amount of time and resources providers and patients spend navigating the process and promote quicker patient access to needed therapies:
- Ensure that patients do not have to repeatedly “clear” prior authorization and step-therapy hurdles each year or each time they change plans;
- Require Part D plans to have a distinct formulary committee for Medicare’s elderly and disabled populations;
- Require that Part D formulary committees have a clinical expert for each therapeutic area it seeks to limit, as well as experts in geriatrics and care for disabled populations;
- Increase Part D and Medicare Advantage (MA) plan accountability for utilization-management tools by reducing opportunities for PBMs to generate a revenue stream for implementing them;
- Ensure that each level of appeal and reconsideration is a meaningful opportunity for the clinician and patient to demonstrate medical necessity; and
- Reiterate and enforce the MA requirement that plans not restrict coverage for products and services not covered in traditional Medicare.
- Clarify the use of Advance Beneficiary Notice of Noncoverage
The Advance Beneficiary of Noncoverage (ABN) transfers potential financial liability to the Medicare beneficiary, and although it is ostensibly limited to situations where Medicare payment is expected to be denied, it is also being used in claims when clinicians are not certain of certain of coverage and wish to transfer liability. The NHC believes that the use of the ABN is subject to conflicting interpretation, and therefore we urge CMS to either:
- Provide further guidance to clinicians or
- Consider implementing a process through which beneficiaries and providers can secure a clarification on coverage before transferring financial liability to the patient.
- Quality reporting requirements
The NHC believes that CMS’ Quality Payment Program (QPP) contains quality measures that can help payers reward better care, inform providers on when they need to take action to improve care, and enable patients to make better-informed decisions about where to seek care, but it gets little insight on quality from the patient perspective. We urge CMS to:
- Examine simple solutions that might make QPP reporting processes more streamlined for providers and
- Work with stakeholders to identify measures that are more directed toward outcomes patients care most about.
2. Enabling of operational flexibility, feedback mechanisms, and data sharing that would enhance patient care, support the clinician-patient relationship, and facilitate individual preferences.
The NHC believes that the best way to support the clinician-patient relationship and facilitate patient preferences is to incentivize treatment planning and shared decision making throughout the patient journey. Recently, CMS initiated policies designed to improve transparency for patients within an office visit, and the NHC agrees that more informed patients are better able to make heath care decisions consistent with their needs and goals, but the information they are given needs to be meaningful, understandable and related to the patients treatment needs. We urge CMS to:
- Engage stakeholders to develop language on drug costs, price increases, and cost sharing that is clear, consistent, understandable and related to beneficiaries out-of-pocket (OOP) costs; and
- Consider other methods of communication that may be more meaningful and actionable for patients, such as including information about OOP costs and utilization management tools in the Medicare Plan Finder.
3. New recommendations regarding when and how CMS issues regulations and policies and how CMS can simplify rules and policies for beneficiaries, clinicians and providers.
The NHC understands that CMS seeks to balance the public interest in ensuring stakeholders have a meaningful opportunity to inform important policy changes with the Agency’s interest in streamlining implementation of refinements that might improve the quality of care, reduce burden of patients and providers, and/or result in cost savings, and thus we urge CMS to do following;
- Take a conservative approach in favor of stakeholder engagement and limit its use of sub-regulatory guidance to minor refinements that are unlikely to have substantial impact on beneficiaries;
- Provide proper notice and opportunity for comment; and
- Ensure that patient and caregiver communities have enough time to review policy changes, assess potential impact, and submit comments.
Please read our comment letter, which providers far greater detail on the NHC’s response to CMS’ RFI.