Lloyd Smucker Asks Healthcare Witnesses: How Do Prior Authorizations ‘Create Barriers To Coverage’?

yesterday

During a House Ways and Means Committee hearing held before the congressional recess, Rep. Lloyd Smucker (R-PA) questioned healthcare witnesses about how prior authorizations can change coverage.

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Transcript

00:00And, Mr. Smucker, you're recognized.

00:05Thank you, Mr. Chairman, for holding this important hearing, and I'd like to thank each

00:09of the witnesses for sharing your testimony today.

00:13You've explained how important post-acute care is, how vital of a role it serves in

00:18our nation's healthcare system, with roughly 40 percent of Medicare beneficiaries receiving

00:24this type of care after inpatient hospital stays, and you've also talked about how that

00:30helps them to recover and stay healthier for longer.

00:33I've spoken to constituents in my district about the services that they've received through

00:39skilled nursing facilities, home health, patient rehabilitation facilities, and other care

00:44settings, and understand and agree with the importance of continuing to make improvements

00:50to the Medicare program so these services continue to be accessible for all seniors.

00:55I'd like to highlight just a little bit the LTACHs, the long-term care hospitals, which

01:01serve the most complex patients who are in need of specialized care but are facing waves

01:06of closures.

01:07I've heard that from folks in my district as well.

01:11And these are the hospitals that, or if these closures continue, patients with the most

01:18severe conditions won't have the level of care that they need.

01:22We've heard reports of Medicare Advantage plans delaying or denying coverage.

01:27You've mentioned that earlier today for LTACH services, and why I believe that MA has been

01:34a game-changer in allowing seniors that access to better, more comprehensive health coverage.

01:40I'm concerned by some of the obstacles to care, which could lead to costly complications

01:47for patients.

01:48Mr. Dungeli, we've heard a little talk about prior authorization just a little bit ago,

01:56but can you describe some of your experiences with prior authorization and talk about how

02:03those may create barriers to coverage and how that impacts the care that your patients

02:08receive?

02:09Thanks again for the question.

02:16The delays once an assessment is done on a patient who has Medicare Advantage and working

02:21through the appeal process is time-consuming and resource-intense.

02:29It delays that patient's access.

02:32And at times, the patient then and the hospital that's referring them may not want to work

02:40through that process with us.

02:41And so as a result, we'll discharge the patient to a less intense setting where they don't

02:47receive the care that they need, or they stay in the acute care hospital and create throughput

02:55issues for that hospital because they can't discharge them.

02:59So it literally could lead to patients being required to leave your facility and not receiving

03:04the care that is needed.

03:05Correct.

03:06I appreciate you sharing that.

03:08And I'd also like to touch on home health as well.

03:11We know that patients recover quicker, have better experiences when they receive care

03:16in their homes.

03:19Occupational therapy is one of the services that seniors can receive through the Medicare

03:23Part A home health benefit.

03:25However, as you know, the outdated statute prevents occupational therapists from treating

03:30a patient in their home unless they're accompanied by another provider, which creates a strain

03:36on medical providers and complicates this access to care.

03:40Yesterday, I introduced a bill with Mr. Doggett and several other colleagues to streamline

03:45the process and allow occupational therapists to provide standalone services in the home

03:49health benefit.

03:51Dr. Madison, you also noted in your written testimony that on average, one 60-day period

03:58of care of home health costs less than one treatment in an emergency room.

04:02So I think there are huge cost savings here.

04:06So, Dr. Madison, how would a bill like the one I've described streamline patient access

04:12to care?

04:13And can you expand on the financial implications this would have for the Medicare system?

04:18Yes, sir.

04:19We're paid for an episode of care, irregardless of what services we provide.

04:24However, if OT could stand on its own, then an OT could provide all the services needed

04:30instead of a nurse having to do the admission and the discharge.

04:36Can you give any sense on what kind of cost savings that would create?

04:42It would not, because we get paid for an episode.

04:45We get paid based on the diagnosis, the function of the patient, that kind of thing.

04:48What it would save is the expenses that the agency is having to spend.

04:52Yes.

04:53All right.

04:55Mr. Chairman, I yield back.

Lloyd Smucker Asks Healthcare Witnesses: How Do Prior Authorizations ‘Create Barriers To Coverage’?

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