Bill Overview
Title: Reducing Medically Unnecessary Delays in Care Act of 2022
Description: This bill requires Medicare coverage decisions, including prior authorization requirements and adverse coverage decisions, to be based on written clinical criteria that is developed in consultation with physicians.
Sponsors: Rep. Green, Mark E. [R-TN-7]
Target Audience
Population: Medicare beneficiaries and associated healthcare providers
Estimated Size: 63000000
- Medicare primarily serves U.S. citizens aged 65 and older, certain younger individuals with disabilities, and people of any age with End-Stage Renal Disease.
- The bill impacts all Medicare beneficiaries, as it pertains to Medicare coverage decisions, including prior authorization requirements.
- There are approximately 63 million people enrolled in Medicare in the United States as of 2022.
- The bill indirectly affects healthcare providers and administrative bodies involved with Medicare due to changes in how coverage decisions are made.
Reasoning
- The Medicare population includes a diverse group of individuals with different health conditions and needs. Among these, some may encounter medically unnecessary delays due to existing practices around prior authorization and coverage decisions.
- The policy aims to streamline the process and reduce these delays by leveraging clinical criteria developed with direct physician input, potentially resulting in faster access to necessary care.
- Considering the diverse needs and healthcare utilization among Medicare beneficiaries, the impact of the policy will vary. Some, especially those with chronic conditions or requiring frequent procedures, may experience a higher impact.
- Many Medicare beneficiaries are located in urban areas where healthcare access is better, but rural beneficiaries, who already face more challenges, might see greater benefits if delays are reduced.
- The expenditure limit implies that while implementation can support a large number of people, the direct and significant enhancements are most likely to be seen in cases where prior authorization delays currently cause considerable access issues.
Simulated Interviews
Retired teacher (New York City, NY)
Age: 72 | Gender: female
Wellbeing Before Policy: 6
Duration of Impact: 10.0 years
Commonness: 15/20
Statement of Opinion:
- Currently, there are a lot of hoops to jump through with Medicare when trying to manage my diabetes care.
- Reducing the waiting time for authorizations would make managing multiple prescriptions easier and less stressful.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 6 | 6 |
| Year 2 | 7 | 6 |
| Year 3 | 7 | 6 |
| Year 5 | 8 | 6 |
| Year 10 | 7 | 6 |
| Year 20 | 6 | 5 |
Retired engineer (Phoenix, AZ)
Age: 68 | Gender: male
Wellbeing Before Policy: 5
Duration of Impact: 20.0 years
Commonness: 12/20
Statement of Opinion:
- The constant back-and-forth for prior authorizations for my treatments is exhausting.
- If they can simplify the process, it would take a load off my mind.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 6 | 5 |
| Year 2 | 7 | 5 |
| Year 3 | 8 | 5 |
| Year 5 | 7 | 5 |
| Year 10 | 8 | 5 |
| Year 20 | 7 | 4 |
Retired farmer (Rural Montana)
Age: 76 | Gender: female
Wellbeing Before Policy: 6
Duration of Impact: 20.0 years
Commonness: 5/20
Statement of Opinion:
- Getting specialist care here is already tough, and the waiting for Medicare approval adds to it.
- Any reduction in delays would be welcome. It would make a real difference for rural folks like me.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 7 | 6 |
| Year 2 | 8 | 6 |
| Year 3 | 8 | 7 |
| Year 5 | 8 | 7 |
| Year 10 | 8 | 7 |
| Year 20 | 8 | 6 |
Retired (Chicago, IL)
Age: 85 | Gender: male
Wellbeing Before Policy: 4
Duration of Impact: 15.0 years
Commonness: 10/20
Statement of Opinion:
- I'm tired of waiting for Medicare approvals for every little thing.
- A faster process would make life more manageable, especially when dealing with multiple conditions.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 5 | 4 |
| Year 2 | 6 | 4 |
| Year 3 | 6 | 4 |
| Year 5 | 7 | 4 |
| Year 10 | 6 | 4 |
| Year 20 | 5 | 3 |
Part-time consultant (Miami, FL)
Age: 66 | Gender: female
Wellbeing Before Policy: 7
Duration of Impact: 5.0 years
Commonness: 20/20
Statement of Opinion:
- I haven't had too many issues with coverage yet, but I hear the stories of delays.
- It's good to know they are working on this, just in case my health needs increase.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 7 | 7 |
| Year 2 | 7 | 7 |
| Year 3 | 7 | 7 |
| Year 5 | 7 | 6 |
| Year 10 | 6 | 6 |
| Year 20 | 5 | 5 |
Retired (Los Angeles, CA)
Age: 71 | Gender: female
Wellbeing Before Policy: 6
Duration of Impact: 10.0 years
Commonness: 13/20
Statement of Opinion:
- My recovery has been slow partly because of waiting on approvals.
- If this policy makes things faster, it could greatly aid recovery times for surgery patients.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 7 | 6 |
| Year 2 | 8 | 6 |
| Year 3 | 8 | 6 |
| Year 5 | 7 | 5 |
| Year 10 | 6 | 5 |
| Year 20 | 6 | 5 |
Retired teacher (Houston, TX)
Age: 69 | Gender: male
Wellbeing Before Policy: 5
Duration of Impact: 15.0 years
Commonness: 14/20
Statement of Opinion:
- There's a real struggle with getting timely approvals for the treatments I need.
- Streamlined processes would truly help those like me who are heavily reliant on medical services.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 6 | 5 |
| Year 2 | 6 | 5 |
| Year 3 | 7 | 5 |
| Year 5 | 6 | 5 |
| Year 10 | 7 | 5 |
| Year 20 | 6 | 4 |
Retired nurse (Seattle, WA)
Age: 74 | Gender: female
Wellbeing Before Policy: 6
Duration of Impact: 15.0 years
Commonness: 11/20
Statement of Opinion:
- As a former healthcare worker, I know these delays are not just frustrating, they're dangerous.
- Improving this could significantly improve the lives of many.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 7 | 6 |
| Year 2 | 7 | 6 |
| Year 3 | 8 | 6 |
| Year 5 | 8 | 6 |
| Year 10 | 7 | 6 |
| Year 20 | 6 | 5 |
Retired lawyer (Boston, MA)
Age: 92 | Gender: male
Wellbeing Before Policy: 3
Duration of Impact: 5.0 years
Commonness: 8/20
Statement of Opinion:
- At my age, every little delay in care is worrisome.
- I hope this policy would make the care delivery smoother.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 4 | 3 |
| Year 2 | 5 | 3 |
| Year 3 | 5 | 3 |
| Year 5 | 5 | 3 |
| Year 10 | 5 | 3 |
| Year 20 | 4 | 2 |
Retired (Atlanta, GA)
Age: 70 | Gender: female
Wellbeing Before Policy: 7
Duration of Impact: 10.0 years
Commonness: 18/20
Statement of Opinion:
- I enjoy being active, and these delays sometimes hold me back from doing things I love.
- Quicker responses would help keep me on the move.
Wellbeing Over Time (With vs Without Policy)
| Year | With Policy | Without Policy |
|---|---|---|
| Year 1 | 7 | 7 |
| Year 2 | 8 | 7 |
| Year 3 | 8 | 7 |
| Year 5 | 8 | 7 |
| Year 10 | 7 | 6 |
| Year 20 | 7 | 6 |
Cost Estimates
Year 1: $200000000 (Low: $150000000, High: $300000000)
Year 2: $180000000 (Low: $130000000, High: $280000000)
Year 3: $190000000 (Low: $140000000, High: $290000000)
Year 5: $210000000 (Low: $160000000, High: $310000000)
Year 10: $230000000 (Low: $180000000, High: $330000000)
Year 100: $250000000 (Low: $200000000, High: $350000000)
Key Considerations
- The number of beneficiaries and breadth of coverage might influence both costs and savings significantly.
- Potential legal and technological hurdles in implementing new clinical criteria need consideration.
- The administrative and operational change dynamics could vary significantly across regions.