Congress should advance patient-friendly policies that improve provider decision-making

At the start of the 118th Congress, a looming question on health care policy was whether a divided government could open a window for the emergence of progressive, bipartisan, common-sense health care policy. Although we have to wait and see, what we do know is that there is a consensus in Washington that many of the problems we face today are not going to go away on their own.

For example, last year it looked like in a year-end package, Congress might take action to delay the 4.5% reduction in Medicare payments for doctors. Had it been successful, there would have been recognition of the severe impact these widespread payment reductions would have on providers grappling with soaring medical inflation, rising labor costs, and the shift to value-based care – but instead of addressing the need for financial stability and predictability, we have seen some reductions implemented and others simply postponed.

For specialists like me, Medicare’s doctor payment cuts further exacerbate the other headwinds we face. Rheumatologists, who treat rheumatic diseases as arthritis which is the leading cause of disability in this country, facing a myriad of unique challenges from insurance companies to provide patients with access to innovative therapies, including biologics, immunotherapies and even biosimilars at lower cost. Unfortunately, insurance company practices often impede our patients’ timely access to care, creating unnecessary delays in needed treatment and services.

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

First, it’s time to reform prior authorization — the often lengthy process of getting payers’ approval for specific therapies or procedures before doctors can treat their patients. This process increases the time patients wait to receive the care they need and puts their condition on hold. It also monopolizes doctors’ administrative time filling out forms and appealing denials – adding to physician burnout.

last Congress, the An Act to improve rapid access to care for seniors passed through the House but died in the Senate. It’s time to resume that effort, because this bill would help modernize and streamline certain pre-authorization processes in the popular Medicare Advantage program. Lawmakers should also follow Rep. Buddy Carter (R-Ga.) carry out as it continues to shine a light on the abuses of Pharmacy Benefit Managers (PBMs) that contribute to the higher costs patients pay for their prescriptions. Senator Maria Cantwell (D-Wash.) PBM Transparency Act (S.127) is also a good start for empowering drug price negotiations.

Step therapy – in which insurers first require cheaper drugs to be prescribed before moving on to more expensive versions – is also in desperate need of reform. These types of fail-first policies, included in employer-sponsored health care plans, are based solely on cost and serve to delay patients’ access to effective therapies. Equally alarming, these policies put the onus on insurance companies, not practicing physicians, to make 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 clarify the process for patients.

Finally, it is high time for Congress to address the use of co-pay accumulators, which insurance companies exploit to take advantage of the cost-sharing assistance patients receive from drugmakers. Ultimately, this practice shifts the costs of specialty medications onto the patients themselves. Congress can address this issue through legislation requiring health plans to count the value of co-pay assistance toward cost-sharing requirements for patients. This would help ensure that all payments, whether made directly by patients or through co-payment assistance from drugmakers, are considered when calculating out-of-pocket costs under their plan.

These reforms would benefit patients’ health and quality of life while helping physicians, who work at the epicenter of patient-centered care, better mitigate the growing barriers to access created by soaring costs of new therapies.

For decades, we have faced a widespread onslaught of market pressures and policies that undermine the decision-making power of physicians, 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 patient-friendly policies rather than ones that only serve to boost payers’ profits, undermine doctors’ ability to provide high quality healthcare and to create new access barriers for patients.

Christina D. Downey, MD, is assistant professor of medicine and acting chief of medicine for the division of rheumatology and immunology at Loma Linda University School of Medicine and chair of the government affairs committee of the American College of Rheumatology.