On June 28, the House Committee on Energy and Commerce held a hearing on “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans,” where both members of the Committee and witnesses agreed that Medicare Advantage Organizations (MAOs) require additional oversight to ensure taxpayer funds are benefiting America’s seniors and providing high-quality care.

The hearing included witness testimony from Erin Bliss, assistant inspector general at the U.S. Department of Health and Human Services, Leslie Gordon, acting director of health care at the U.S. Government Accountability Office, and James E. Mathews, executive director of the Medicare Payment Access Commission.

The Committee expressed concerns for the burdensome process of prior authorization for clinicians, other utilization management policies like step-therapy that delay access to care, excess payments to MAOs related to coding intensity, and use of in-home assessments and/or unlinked chart reviews as the source of diagnosis for payment.

Reps. Raul Ruiz, MD, (CA-36) and John Joyce, MD, (PA-13) included ACC’s concern for step-therapy in their questioning, asking Bliss about what oversight processes are in place to ensure that step-therapy, or “fail first” policies, does not prevent care access. Bliss responded that the Office of the Inspector General will consider new research to investigate the issue and recognized that step-therapy can inappropriately eliminate access to care and worsen beneficiary health outcomes.

Coming out of the hearing, multiple policy solutions were proposed. To combat issues related to prior authorization, the Committee discussed the option of gold carding to approve clinicians with a history of submitting accurate data and implementing an electronic submission system to reduce administrative burden and human error.

In addition, Rep. Larry Bucshon, MD, (IN-08) joined the hearing as a guest of the Committee encouraging members to co-sponsor the Improving Seniors’ Timely Access to Care Act of 2021 (H.R. 3173), a bill with ACC support addressing prior authorization reform.

Clinical Topics: Cardiovascular Care Team, Geriatric Cardiology

Keywords: Financial Management, Hearing, Commerce, Government, Electronics, Social Responsibility, Outcome Assessment, Health Care, United States Dept. of Health and Human Services, Policy, Health Services Accessibility, Prior Authorization, Private Sector, Medicare Part C, Aged, ACC Advocacy

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