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ACG to lawmakers: Support legislation to remove GI care barriers
Last week, American College of Gastroenterology governors from across the country gathered in Washington, D.C., to discuss important legislative issues with lawmakers on Capitol Hill.
Of note, they urged their representatives to support S. 479 and H.R. 1017, two bills known collectively as the Removing Barriers to Colorectal Cancer Screening Act, which would improve access to colorectal cancer screening for Medicare beneficiaries. Additionally, the governors advocated for the passage of H.R. 2077, the Restoring the Patient’s Voice Act, which would provide exemptions to “step-therapy” requirements that force patients – such as those with inflammatory bowel disease – to try and fail certain therapies before gaining access to medications originally prescribed by their provider.
Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF, chair of the ACG Board of Governors, recently told Healio Gastroenterology and Liver Disease about the ACG’s advocacy efforts and explained why this legislation is so important for patients and providers.
Healio: What specific changes would result from the passage of S. 479 and H.R. 1017, and how would they help remedy the problem of the colonoscopy loophole?
Kefalas: The federal government requires private plans governed under the ACA to waive cost sharing when a screening colonoscopy turns “therapeutic.” What that means is when a person sees me for a screening colonoscopy (no other symptoms) and I remove a polyp, this is no longer considered “screening.” Thus, different rules apply. In Medicare, CMS does not believe it has the authority to waive cost sharing. However, other private plans in the ACA must waive cost sharing in this scenario. The bill allows for this change to occur in Medicare. Closing the loophole would provide clarity and remove a financial barrier to colonoscopy for Medicare patients.
Healio: Does this legislation go far enough, and what is the likelihood that it will pass within the year?
Kefalas: The legislation is important but does not cover all problems associated with cost sharing and colorectal cancer screening. The bill applies to Medicare only, and does not address the issues when a patient is referred for a colonoscopy after another CRC screening — a stool test for example.
It is frustrating, as the GI societies and others have been advocating for this bill and others since the quirk was first discovered in 2010, after the [ACA] was signed into law. Currently, more than one half of the members in both the House and Senate support the bill. The bill enjoys significant bipartisan support yet because there is a cost to the federal government for its implementation, we must continue to advocate for more support and passage. We believe that closing the loophole would ultimately save the federal government money by spending more on colon cancer prevention rather than on colon cancer treatment.
Healio: How would H.R. 2077 improve access to therapies that were otherwise out of reach due to step therapy policies?
Kefalas: “Step therapy” and prior authorization requirements are detrimental to patient care, notably in diseases such as inflammatory bowel disease (IBD). These insurance coverage requirements infringe on the physician-patient relationship, are not based on medical literature, do not improve patient outcomes, and do not lower health care costs. GI practices spend a significant amount of resources dealing with insurance denials and coverage issues. This is overly burdensome for GI practices, leads to poor health outcomes, and takes away from valuable time that could be spent with patients.
The College continues to stress the critical importance in protecting the relationship between the physician and patient. This requires an environment in which we, as treating physicians, along with our patients can decide the best and most appropriate course of treatment without interference from policies tied solely to economic or other non-medical issues. The bill would eliminate both the delay patients often face to receive the right treatment and the requirement to try and fail other costly drugs first.
Healio: Does this legislation go far enough, and what is the likelihood it will pass? Has it received any pushback from health insurance lobbyists?
Kefalas: The Restoring the Patient’s Voice Act of 2017 has been introduced only in the House of Representatives. There is no Senate version of the bill. Also, it applies only to self-insured plans (large groups) covered by ERISA. However, there is a movement in various states (Massachusetts and Minnesota, among many others) to pass similar legislation. This is one example of the practice management challenges ACG members face when dealing with prior authorizations and insurer coverage requirements.
It is unclear which health insurance lobbyists oppose these bills. ACG continues to work with patient advocates, professional societies, and others to educate policymakers in response to any opposition to these bills.
Healio: What ideas are on the table for reforming prior authorization requirements?
Kefalas: The College is addressing these issues through local advocacy and state bills that allow exemption to step therapy and prior authorization requirements. That is one unique function of the ACG Board of Governors, who are elected by their peers to represent the interests of their colleagues in their state or region. ACG can quickly get involved in state and local issues through our Governors. Many state legislatures and medical societies are actively engaged in this issue as well. There is an Ohio bill (HB 72/SB 56) that would make it easier to obtain medically appropriate exemptions from step therapy for patients. Across the country, ACG Governors and members are actively advocating for these changes at the state and local level.
Disclosures: Kefalas is chair of the ACG Board of Governors.