Dear Honorable Members of the Council of the District of Columbia,
On behalf of the nearly 100 people with cystic fibrosis in the District of Columbia, we write to express our support for B25-0124 — Prior Authorization Reform Amendment Act of 2023, which makes several important reforms to the prior authorization (PA) process. PAs can delay access to critical CF therapies and the Cystic Fibrosis Foundation supports efforts to minimize the administrative burden PAs impose on patients and their providers, promote transparency of PA requirements, and ensure adverse PA determinations are made by qualified physicians. We urge you to support B25-0124 to ensure immediate and consistent access to therapies for people living with CF in the District.
About Cystic Fibrosis
Cystic fibrosis is a life-shortening genetic disease that affects nearly 40,000 children and adults in the United States. CF causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, which can lead to life-threatening infections. CF care is grounded in evidence-based clinical guidelines and as a complex, multi-system disease without a cure, CF requires an intensive treatment regimen including multiple medications. For people with CF, it is not uncommon to take seven therapies every day, and as many as twenty. Many medications are taken year after year, and in most cases, for life. While these therapies are helping people live longer, healthier lives, we also know patients often encounter barriers to accessing them.
Prior Authorizations for People with CF
Prior authorizations are one of the obstacles that people living with chronic conditions, including CF, must navigate when accessing care. These requirements can delay the start or continuation of needed treatments, which can lead to adverse health outcomes. Time-consuming PA requirements can delay the start or continuation of needed treatments, which can lead to adverse health outcomes. In a 2022 survey by the American Medical Association, 94% of physicians reported that prior authorizations led to delays in necessary care for their patients whose treatment required PA and 80% reported that PAs have led to patients abandoning their treatment at some point. Because CF is a progressive disease, patients who delay or forgo treatment—even for as little as a few days — face increased risk of lung exacerbations, costly hospitalizations, and potentially irreversible lung damage.
PAs can also cause significant administrative burden for CF providers and are often redundant for medications that people with CF must take indefinitely to maintain their health. In a CF Foundation survey of CF care teams, 58 percent of providers reported spending 20 percent or more of their time on PAs in 2016. This arduous process diverts valuable time and resources away from direct patient care.
We appreciate the District’s attention to this issue and support the following provisions in B25-0124:
Medications for Chronic Diseases
Recognizing that people with CF and other lifelong, chronic diseases take the same drugs for most of their lives, we appreciate B25-0124’s requirement that PAs for health care services to treat chronic and long-term care conditions remain valid for as long as is medically reasonable and necessary. Eliminating unnecessary repeat authorizations will help promote immediate and consistent access to life-saving therapies for people with CF, and significantly reduce administrative burden for CF care teams.
Response Times and Continuity of Care
B25-0124 requires health plans to respond to all prior authorization requests within three to five business days for non-urgent services or 24 hours for urgent services, thereby ensuring timely access to treatments. Also included in the bill is a continuity of care provision that protects patients from experiencing care delays when there are changes in coverage for a given treatment or when patients switch health plans. As stated previously, CF maintenance requires many chronic medications, and gaps in therapy put people with CF at increased risk of costly hospitalizations and negative health outcomes. We support efforts to reduce delays in care and ensure people have timely access to their necessary medications.
Transparency for Prior Authorization Requirements
The CF Foundation applauds the provisions of B25-0124 to increase transparency for PAs, specifically the intent to mandate that insurers make their PA requirements and criteria — and changes to these policies — easily accessible via their website and upon request. People with CF take many medications every day, many of which require prior authorizations. Each additional prior authorization can further exacerbate the administrative burden on both people with CF and care teams as they navigate the criteria required to obtain these medications. Increasing the availability of information on prior authorization requirements and processes at the point-of-care will help reduce the administrative burden of these policies and streamline the process for care teams.
Evidence-Based Review
One of the purposes of prior authorization is to verify the clinical appropriateness of a service, so it is crucial that insurers use evidence-based criteria when developing prior authorization requirements. CF treatments have very clear indications established by the Food and Drug Administration and it is essential that prior authorization criteria reflect the data and label approval. To that end, B25-0124 requires that PA denials must be made by a licensed physician who specializes in managing the medical condition or has experience providing the requested service.
The Foundation appreciates that PA policies were adopted to ensure patients only receive medically necessary care, and we understand the challenge insurers face in managing medication utilization and cost. However, utilization management cannot come at the expense of delays in patient access to needed care. B25-0124 provides an opportunity to make prior authorization processes more transparent, efficient, and evidence-based, allowing for timely access to appropriate treatments.