‘Unsustainable’: Medical groups say regulatory burdens are rising, and hurting patients

Medical groups say they are struggling to deal with mounting administrative burdens, and the headaches are taking a toll on patient care and weighing heavily on staff.

The Medical Group Management Association released its annual report on regulatory burdens this week, and the vast majority of practices said the hassles are getting worse.

About 9 out of 10 (89%) groups said the regulatory burden on their practice has grown in the past 12 months. Nearly all respondents (97%) said a reduction in regulatory requirements would allow them to focus on patient care.

As in past years, groups cited payers’ requirements of prior authorization for medical treatments as the top regulatory burden. More than four out of five (82%) medical groups said prior authorization requirements are very or extremely burdensome. Only 2% of respondents said prior authorization requirements weren’t burdensome.

The vast majority (95%) said patients were denied or delayed medically necessary care due to prior authorization requirements. And 89% of groups said they hired staff or redeployed staff to handle the increasing demands of prior authorization requests.

Medical groups, hospitals and healthcare organizations are pressing Congress for relief. Health groups are optimistic about the prospects of a bill that would streamline prior authorizations in Medicare Advantage programs, which serve 28 million Americans.

The House of Representatives passed the bill last month, and it’s now before the Senate. Advocates say there’s strong bipartisan support for the bill. The bill would require an electronic prior authorization process, and Medicare Advantage plans would be required to disclose the approval and denial rates of authorization requests.

Lawmakers need to pass the measure, Anders Gilberg, MGMA’s senior vice president of government affairs.

“The increase in prior authorization requirements year after year is simply unsustainable,” Gilberg said in a statement. “Practices are being forced to divert resources away from delivering care to contend with these onerous and ever-changing requirements. It is time that Congress acts to put commonsense guardrails around prior authorization programs. We urge the expedient passage of the Improving Seniors’ Timely Access to Care Act before the end of this year.”

Insurers have touted prior authorization as a critical tool in guarding against wasteful spending and unnecessary treatments. But doctors, hospitals and medical groups all contend payers are putting up too many roadblocks to necessary treatments, and patients are suffering because of it.

The MGMA report cited three top burdens of prior authorization: delays in decisions (89%), inconsistent payment policies (75%) and requirements for authorizations for services and treatments that are routinely approved (73%).

While prior authorization held its top spot on the list of regulatory headaches, medical groups also pointed to other administrative hassles.

Medical groups said the regulatory requirements of the No Surprises Act are taking a toll. The federal law, which went into effect in January, is designed to prevent patients from being socked with unexpected bills from out-of-network providers. The MGMA says it supports protecting patients from being unfairly gouged, but some requirements are hampering medical groups.

Roughly four out five groups (82%) said they have seen greater administrative burdens from  requirements to provide good faith estimates for those without insurance or patients who are paying out of their own pocket. Nearly three quarters (74%) of respondents said they don’t have the infrastructure to comply with new requirements that are taking effect next year.

Medical groups also said they are frustrated with some new Medicare requirements designed to improve the quality of patient care. Medicare’s Quality Payment Program includes two new reporting systems: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Most medical groups said they were using the MIPS system.

Most (76%) said the regulatory burden has increased with the shift to value-based payment, while nearly two-thirds (64%) said it wasn’t leading to better care for patients.

“In a time of runaway inflation and unprecedented workforce shortages, the federal government is layering on additional regulatory burdens that, while in theory are beneficial to patients, act more as an impediment to delivering care,” Gilberg said in a statement.

“From longstanding challenges associated with the Quality Payment Program, to new obstacles related to the No Surprises Act, it is evident that policymakers must consider the totality of these burdens and their ultimate impact on patient care,” he said.

The MGMA report included responses from more than 500 medical groups.