The Centers for Medicare & Medicaid Services (CMS) released a final rule last week intended to expedite the prior authorization process for those covered by Medicare Advantage, Medicaid and Children’s Health Insurance Program (CHIP) plans.
Under the new rule taking effect in 2026, Medicare Advantage, Medicaid and CHIP plans will have 72 hours to answer urgent requests and seven days for a standard request. Affected payers will also be required to provide a specific reason when denying requests, as well as publicly report certain prior authorization metrics.
Additionally, the rule will require affected payers to implement a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface (API) to support electronic prior authorization. Payers must expand patient access to APIs beginning in 2027 to include information about prior authorizations. They must also implement a provider access API that providers can use to retrieve their patients’ claims, encounters and clinical and prior authorization data.
These actions addressing prior authorization come amid conversations on this same issue on Capitol Hill. The House Ways and Means Committee advanced the bipartisan Improving Senior’s Timely Acccess to Care Act in 2023, which gained traction following a report from the U.S. Department of Health and Human Services highlighting abuse of the prior authorization program and a letter signed by 233 House and 61 Senate members urging action by the CMS. The bill would have required plans to adopt a “real time” process for answering routinely approved items and a 24-hour response for any urgent requests. The release of the final rule may pre-empt further legislative action.
Members with questions should contact Megan Blue at the MHA.
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Effective Oct. 1, the Michigan Department of Health and Human Services (MDHHS) will transition the telephone prior authorization process from Admissions and Certification Review to the MDHHS Program Review Division. This applies for the …
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Nonetheless, the parallels between the current state of worker sentiment in the U.S. auto manufacturing and healthcare services sectors are instructive. Auto and healthcare workers want job security and higher pay, believing their company executives and boards but corporate profit above their interests and all else. And polls suggest the public’s increasingly sympathetic to worker issues and strikes like the UAW more frequent. …”
To help Medicaid beneficiaries with the renewal process, a redetermination event is being hosted by the Salvation Army Great Lakes Harbor Light System in Grand Rapids from 10 a.m. to 2 p.m. on Sat, Sept. 30.
Effective Oct. 1, the Michigan Department of Health and Human Services (MDHHS) will transition the telephone prior authorization process from Admissions and Certification Review (ACRC) to the MDHHS Program Review Division. This applies for the following services:
Durable medical equipment and supplies, limited to: Enteral/parenteral nutrition/supplies, negative pressure wound therapy, home infusion therapy and home uterine activity monitors.
These changes only apply to Medicaid and Children’s Special Health Care Services fee-for-service. On and after Oct. 1, 2023, members are urged to use 1-844-PACERMI (1-844-722-3764) to request authorizations of the above services. All policy standards of coverage, telephone prior authorization processes and documentation requirements remain unchanged.
Members are able to refer to Medicaid Letter L-23-55 for more details. Members with questions may contact Kelsey Ostergren at the MHA.
Manufacturing delays at several pharmaceutical companies are causing nationwide shortages of two critical chemotherapy medications – forcing Michigan hospitals and health systems to find alternative treatments for patients, some of which may be less effective. The two drugs are cisplatin and carboplatin and are used to treat several types of cancer, including bladder, lung, ovarian and testicular cancers. The shortage of these chemotherapy drugs is widespread across the country, impacting hospitals throughout all regions of Michigan.
Both drugs are provided by healthcare providers as injections to oncology patients. The shortage of cisplatin was originally reported to the U.S. Food & Drug Administration (FDA) Feb. 10, 2023, while carboplatin was reported April 28, 2023. Both shortage durations are expected to last at least into June 2023.
To reduce the impact of shortages on patients, hospitals are trying many different solutions, including managing existing supply, seeking alternative sources for drugs in short supply, adjusting chemotherapy regimens for impacted patients and working with healthcare systems, as well as state and federal officials, to mitigate these challenges.
“The priority of hospitals is delivering the right care to every patient, every time,” said MHA CEO Brian Peters. “Drug shortages severely hamper a hospital’s ability to provide patients with the best treatment, while forcing hospitals to implement strategies that may increase the cost of care and sometimes do not offer the same effectiveness in treatment.”
This current shortage follows a national trend of drug shortages impacting healthcare providers for years. A survey of medical oncologists published in the New England Journal of Medicine found 83% were unable to prescribe their preferred chemotherapy agent due to shortages.
The MHA supports the following strategies that will address the issue:
Relaxing prior authorization requirements from health insurers for alternative therapies so they can be widely used, as appropriate.
Establishing an early warning system to help avoid or minimize drug shortages.
Removing regulatory obstacles faced by manufacturers and the FDA as a way of averting or mitigating drug shortages and allowing drug imports.
Improving communication with healthcare providers, including extent and timeliness of information. There often is no transparency on the cause of a drug shortage and many shortages occur with generic drugs.
Exploring incentives to encourage drug manufacturers to stay in, re-enter or initially enter the market.
Patients concerned about the impact of this drug shortage should contact their healthcare provider.
The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to modify the prior authorization process for certain payers. The proposal would require payers to:
Include a specific reason when denying a request.
Publicly report certain prior authorization metrics.
Make decisions within 72-hours for urgent requests.
Make decisions within seven days for standard, non-urgent requests, which is twice as fast as existing Medicare Advantage response timelines.
Enable improved data exchange.
The proposal generally applies to Medicare Advantage, Medicaid and Medicaid managed care and Children’s Health Insurance Program (CHIP) and CHIP managed care plans, as well as qualified health plans on the federally facilitated exchanges. Members are encouraged to review the proposal and submit comments to the CMS by the March 13, 2023 deadline.
Members with questions should contact Jason Jorkasky at the MHA.
“Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.” ― Rudolf Virchow
As we enter the final two months of the MHA program year, our “all-hands-on-deck” prioritization of the healthcare workforce continues, and I am pleased to share that we have made significant strides in this regard. Included in that progress is work with our partners in higher education, other Michigan healthcare associations, hospital clinical leaders and the Michigan Legislature.
One aspect of our workforce efforts is not new. For many years, the MHA has led a special Graduate Medical Education (GME) Advocacy Day, hosted at our MHA Capitol Advocacy Center (CAC) in downtown Lansing. At this event, medical students, residents from teaching hospitals and academic medical centers, and other key leaders converge on the Capitol and meet with legislators to discuss the vital importance of GME funding in the state budget process.
After a brief hiatus due to the pandemic, we are excited to play host once again for this important in-person event, as we will welcome our colleagues to the CAC on May 5.
When this event began, the primary focus was to express the importance of GME and the national prominence that Michigan has earned in medical education. We have more than 7,200 physician residents currently working in the state, which ranks fourth in the nation. In addition, Michigan is third in the country for student enrollment in public medical schools. The investment Michigan makes in GME is very valuable, as every $1 in GME generates $2.53 in federal funding in fiscal year 2022. While the current rate is enhanced due to the existing public health emergency, there is no question that GME funding for Michigan’s beginning physicians is a wise investment for the future healthcare workforce in our state. GME also improves access to care, as it allows physicians to further their medical education while delivering much-needed care to patients throughout Michigan in teaching hospitals, community clinics and laboratories.
The vital role of GME in filling the talent pipeline is more important today than ever, as Michigan hospitals (and the healthcare delivery system in general) struggle with workforce shortages that have been exacerbated by the COVID-19 pandemic. Those shortages across the state have caused Michigan to lose approximately 1,300 staffed hospital beds over the past 18 months. Nationally, the physician shortage is estimated to be between 37,800 and 124,000 by 2034, including primary care and nonprimary care specialties, as the Association of American Medical Colleges estimates two out of every five active physicians will be 65 or older within the next 10 years.
The participants in our GME Advocacy Day have experienced many of the challenges that we’ve shared with elected officials: stress, burnout, workplace violence, vaccine hesitancy and significant loss of life due to COVID-19 and a host of other medical issues. Their perspective is extremely valuable as we make the case for funding and public policy that ensures the viability of our healthcare infrastructure for years to come. In addition to full funding of the traditional GME pool, there are several related items on the radar screen here in Lansing, including:
Included in the state’s Higher Education budget proposal is House Bill 5785, which would provide funding to create a healthcare workforce collaborative between the MHA and Michigan’s public and private post-secondary educational institutions. This partnership would not only provide employers with a better understanding of statewide graduates in health professions, but further improve the knowledge of employment opportunities in healthcare for post-secondary education institutions throughout the state. Included in the collaborative would be the creation of a searchable and accessible repository that allows healthcare employers to understand current educational trends and provides prospective employees easy access to healthcare positions throughout the state.
The MHA also supports legislation designed to incentivize more medical school and advanced practice nursing program preceptors by providing new tax credits. Senate Bills 998 and 999 would create a new tax credit for individuals who agree to work as a preceptor for required clinical rotations. We believe this legislation could help increase the capacity for clinical rotations at hospitals across the state, which would also improve the talent pipeline.
As we advocate in support of GME and related issues, we of course greatly appreciate the collaboration of our friends from the Michigan State Medical Society (MSMS) and Michigan Osteopathic Association (MOA). Together, our three associations make up The Partnership for Michigan’s Health, which has a long history of working together on healthcare issues of common interest, including the achievement of major medical liability reforms in the early 1990s, which established the foundation for much of our advocacy work in the Legislature and the courts ever since.
Most recently, the collective voice of our three associations, along with associations representing various other areas of healthcare, led to successfully securing $300 million in state funding for the recruitment, retention and training of healthcare workers. Collectively, the Healthcare Workforce Sustainability Coalition was created to focus on workers already within the healthcare workforce. Gov. Whitmer also recently signed Senate Bill 247 that would decrease wait times for commercial insurance prior authorization requests, a priority for all three associations. We are also united in our opposition to Senate Bill 990 that would create a serious public health risk by licensing naturopathic practitioners and classifying them as physicians. As healthcare associations, the professional careers of our members are dedicated to serving their patients and protecting the health and safety of the public. This opposition is an example of our need to protect the public from a practice that lacks scientifically proven treatment methods and clinical training.
In addition, we have long collaborated with MSMS and MOA to produce The Economic Impact of Healthcare in Michigan Report, which provides a detailed look at the extensive roles hospitals and health systems play in their local economies. Work is underway on the next issue of the report. The MHA Keystone Center Board of Directors has also designated one seat each for the MSMS and the MOA since its inception to ensure physician representation as we strategize on safety and quality improvement issues. And finally, the MHA and the MOA literally got closer last year when the MOA relocated its offices to the MHA headquarters building in Okemos – an arrangement that is unique anywhere in the country.
I’d also be remiss if I didn’t mention the MHA’s new focus on engaging with our physician leaders. For the first time ever, the MHA will be hosting activities dedicated to our physician leaders during our MHA Annual Meeting, including several sessions that will include CME credits. MHA Chief Medical Officer Dr. Gary Roth is leading these efforts, which complement his work throughout the pandemic engaging with our health system chief medical officers to facilitate consistent and reliable dialogue that allowed the MHA to efficiently provide policy updates to our clinicians as well as real-time feedback to policymakers. We’re extremely fortunate to have Dr. Roth, as the MHA is one of just a few state hospital associations with a full-time CMO on its leadership team.
Lastly, in an effort to fully support our physician colleagues (and other caregivers), the MHA Keystone Center is offering the Well-being Essentials for Learning Life-Balance (WELL-B) webinar series to prevent healthcare burnout by delivering weekly webinars on evidence-based well-being topics, including prevalence and severity of burnout, relationship resilience and being present. It is encouraging to see that over 4,000 individuals have already signed up for this innovative program.
As you can see, there is no magic pill that can solve the healthcare staffing crisis overnight. It will take many years and a multitude of public and private solutions to protect access for all of Michigan’s communities. GME is one of those key solutions, and we call on our elected officials – and all Michiganders – to give it the support it deserves.
Legislation to decrease wait times for commercial insurance prior authorization requests was signed into law by Gov. Gretchen Whitmer April 7. Senate Bill (SB) 247, introduced by Sen. Curt VanderWall (R-Ludington), will shorten the timeline for approval to seven calendar days or 72 hours for urgent requests, as well as ensure that emergency care can be provided without prior approval.
Shortening wait times for prior authorization requests has been an MHA priority for several legislative sessions. The MHA provided testimony in support of SB 247 in both chambers and shared a letter with the governor encouraging her to sign the bill. The legislation will take effect June 1, 2023.
Members with questions about SB 247 or other state legislation regarding healthcare should contact Adam Carlson at the MHA.
Active Fall Committee Work Continues in Legislature
The UAW Strike: What Healthcare Provider Organizations Should Watch
