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Featured topic and speakers
What are the goals of the American Medical Association? Is Medicare unsustainable? Do doctors lose money on Medicare patients? What is the AMA position on prior authorization?
Our guest is AMA Senior Vice President of Advocacy, Todd Askew. AMA Chief Experience Officer Todd Unger hosts.
- The AMA is your powerful ally in patient care. Join now.
- AMA prior authorization survey (PDF)
- Googling "prior authorization laws by state"? Use AMA prior authorization state law chart (PDF).
- AMA prior authorization physician advocacy examples (PDF).
- AMA prior authorization model bill (PDF).
- Wondering what is scope of practice and why is it important? See AMA fighting scope creep examples.
- Searching for why do scope of practice laws vary by state? Access free resources and examples of scope creep PDF.
- AMA efforts to #StopScopeCreep.
- Wondering "What does the AMA lobby for"? Check out the AMA Progress Report (PDF).
- AMA efforts on Medicare payment reform.
- Get involved! Tell Congress to fix Medicare now.
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- See how the AMA fights for physicians.
Speaker
- Todd Askew, senior vice president of advocacy, AMA
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're addressing some of the most common questions that people have about AMA advocacy. Our guest today is the senior vice president of advocacy at the AMA, Todd Askew in Washington, DC. I'm the other Todd, Todd Unger, AMA's chief experience officer in Chicago. Todd, welcome back.
Askew: Hey, thanks for having me, Todd.
Unger: Well, last time we talked was from the floor of the House of Delegates, where a lot took place. And we're going to talk today in a little bit more detail about AMA's priorities for the coming year and get into some of the specific issues on the table. Why don't we just start by talking a little bit about, what shapes the priorities for AMA advocacy for, let's say, the coming year?
Askew: Sure, Todd. Well, as we discussed the last time we were together, a lot of the work, a lot of the prioritization comes from the House of Delegates. That's where our policies come from, adopted by more than 170 medical specialty organizations, states and specialties alike, coming together to propose and debate policies. That informs most of our work. It informs almost all of our advocacy work.
Of course, we have a lot of discussions within the AMA Board of Trustees, and our strategic plan and the priorities adopted there play a large portion, a large part in identifying what those top priorities are.
The number one way, though, I think, is we are told. We hear from the physicians. We see it in polling. We have it in our conversations, in our meetings, in the speeches at the House. What are they most worried about? What are the things that are most impacting their ability to care for their patients and most impacting the future of the profession? And so that is where we put our priorities.
Certainly, we adopted probably 100 new policies at the House just last month. Not everything's going to be at the top of the list. It can't be. They will all get attention. They will all get work. They will all receive the care and the focus that they need.
But there are clearly some that are just more of a concern to physicians than others. And some of those are obviously Medicare payment reform, the administrative burden of prior authorization and burnout, physician wellness. We consistently hear those and others at the very top of the list.
Unger: All right. Well, we're going to focus on three of those items, some of which you named, that are at the top of the list in terms of what is affecting physicians as they practice. Let me just start out with the topic of scope of practice and how we think about this issue of physician-led team based care. Tell us a little bit more about the AMA's position there.
Askew: Sure. So it can be a difficult topic to talk about because we don't want to be a position of devaluing the role that all clinicians play in caring for patients. I think most physicians look at providing care as a team sport, essentially, then working with each person on the care team, commensurate with their training and experience, to provide the best care possible for patients.
But physicians, because of their extensive training and medical education and many, many thousands of hours of clinical experience during that training are just better suited in most cases to provide that care. So it's important that physicians have a—that patients have an opportunity and access to a physician. It doesn't have to be every encounter. It doesn't have to be every service. But the head of that team, if you will, should be someone with the training of a physician to ensure optimal patient care.
Unger: Thank you for clarifying that. That makes a lot of sense. Let's move on to topic number two. Been in the news a lot lately, this issue around prior authorization. Todd, tell us a little bit about some of the improvements that we're advocating for right now.
Askew: Well, prior authorization is what probably comes up most when we speak to physicians—that and Medicare payment. But prior authorization is a driver of the day-to-day frustrations they have with the way medicine is practiced today as a literal barrier that gets between them and their patient in terms of they've worked hard.
They've worked with the patient, maybe the patient's family. They've decided on a care plan. And then they go to the insurer, and it's denied. And then it spins off countless hours, days, sometimes weeks of work by the physician and their staff to get that care approved.
And so when we talk about obstacles to delivering patient care, that really has to be at the very top of the list. We have advocated for a lot of reforms across the Federation of Medicine that focus on, we're not going to get rid of prior authorization. Prior authorization is part of the way the insurance business model works.
But we need to take the friction out of it. We need to reduce the volume of it. We need to make sure that it is truly only for those cases where there may be some question or a very, very expensive treatment that may need—that the payer may want to put another set of eyeballs on.
But what we have now is a system where 30-year-old generic drugs, very common services and therapies, are subject to prior authorization. And it really sometimes seems like for no other reason than to slow down the process, to get between the patient and the benefits that they've paid for with their premium dollars. And sometimes the patients will abandon the care, and the treatment that was felt was necessary will not be delivered. The drug prescription will not be filled.
And that's too bad because we've seen large numbers of physicians have a patient—I mean, the vast majority of physicians have seen negative clinical outcomes on the basis of prior authorization denials. And the sad thing is most of the denials that are appealed are eventually approved, but it takes countless hours of time.
It's the reason physicians spend more time with paperwork than they do with patients now because of the constant battle. And it is a leading driver of burnout and concerns with physician wellness. This entity out there trying to keep you from providing the care you believe that your patient needs. And so it's a really high priority. And we have seen some improvements, or we are in the process of seeing some improvements.
Regulation has been enacted to provide some important changes to the way Medicare Advantage plans can apply prior authorization and some of the tactics they use, as well as some improvements to the tactics used in other federally regulated plans. That's a limited set of plans, but it's an important start. And there's some important reforms that will be coming online in the next couple of years.
We're going to see more scrutiny. We're going to see more public reporting of planned denial rates so that patients, when they're making their choice about a plan, can see how often that plan is denying care. And so the momentum, I think, has continued to build over the last several years as the evidence of the negative impact of prior authorization has really just grown and grown and grown.
So we see very strong trends in right sizing this. We see some payors are getting on board and saying they're going to reduce the amount of prior authorization that's applied because it's not always in the best interest of the patient. We would argue it's rarely in the best interest of the patient.
And so we feel good about this one. It's still a long way to go. There's still a massive burden that PA places on the ability of physicians to care for their patients, but the trends are in the right direction. The consensus is that it needs to be rightsized, and we're excited about where this is going in the future.
Unger: Thank you for that update. Now we've covered two of those key issues that physicians are facing. We talked about scope of practice, and we talked about progress on prior auth. Let's go back to the first thing that you mentioned, which is about Medicare payment reform. This is at the top of everybody's list. It does have such a huge impact on the care team and patients.
Todd, tell us about what you're up to there and what you see in terms of progress.
Askew: Sure. So I think it's important for people to understand this is not just about putting more dollars in doctors' bank accounts, that the Medicare program—I don't think most people realize—payments for physician services under Medicare have essentially been stagnant for the last 20 years. And that means not going up—I mean, basically almost a flat line.
Costs, meanwhile, have gone up 30% over that period of time. So it's equated to about a 30% reduction in the value of the Medicare dollar that is used to treat Medicare patients. This is not only a considerable stress on physicians. It's their ability to keep the office doors open. It's their ability to hire adequate clinical staff, all of which those costs are going up.
So it is not just about more dollars. It is about a sustainable Medicare system that is going to continue to be able to provide access to physicians in the future. Because while you're only starting now to see physicians limiting the number of Medicare patients they see or some leaving Medicare altogether. The Medicare Payment Advisory Commission, which advises Congress on Medicare issues, as well as the Medicare trustees themselves have both this year signaled real concerns with the trajectory of the Medicare physician payment issue and how it will impact, without a doubt, in the long term, Medicare beneficiaries' access to physicians and to care.
And so it is not a just desire for higher payments. It is a necessary ingredient in order to be able to have a sustainable and accessible Medicare system for today's seniors but especially for tomorrow's seniors. And it is the highest priority that we are working on right now because the stakes for the profession and the stakes for patients are so extremely high.
Unger: Todd, any kind of key milestones on the horizon or important progress points?
Askew: Well, we have started to see a large consensus building around the approach that the AMA and all of organized medicine has really taken. There's three introduced pieces of legislation and another proposal out there as well that kind of come together to form the nucleus of what we believe reform should look like.
The first one is inflationary-based updates, making sure that the Medicare payment system for physicians like the Medicare payment system already does for every other category of provider under the Medicare program—hospitals, nursing homes, home health, et cetera—has inflationary-based updates that keep pace with the cost of caring for America's seniors.
The second important factor is to deal with budget neutrality. We see these wide swings in payments sometimes for different services because it's essentially the size of the pie stays the same every year. But we slice it and dice it based on various regulations and legislation differently each year. And so somebody goes up, somebody has to come down.
We've got to grow the slice of that pie with the inflationary updates. We also have to make some important reforms to smooth out and to lessen the impact of those budget neutrality cuts. Thirdly, we need to continue to promote the ability of physicians to engage in alternative payment models and make sure that there are alternative payment models available for those physicians that wish to engage that way to participate in.
And finally, the current quality reporting system under fee for service, the MIPS program, is really a disaster. It's four different components that were kind of jammed together. MACRA was the bill passed a number of years ago.
It is failing. The updates are nonexistent. The relevancy of some of the clinical reporting that's done is non-existent. In fact, the link between quality under MIPS and pure random chance is exactly the same, that MIPS has not shown one bit to actually increase the quality of care being provided.
So we have proposed and are discussing some major reform to MIPS that would really address some of those issues. An important one that I would highlight, for example, is data. Right now CMS is required to provide data to physicians in a timely way so that they can see how they're doing in terms of providing quality care. Right now they're getting that data 18 months plus after the care has been provided instead of quarterly.
You can't go back and improve the care you're providing if you're only learning about it almost two years later. So we would argue that you shouldn't penalize physicians until you can give them the timely data that allows them to improve the quality of care they provide. So that's one example of a number of reforms that we're discussing to the MIPS program.
There has been some folks said we should just scrap the whole thing. And there's a lot of sentiment for that. I understand it. The problem is you're going to get something in its place. That's the concern. And we'd rather help have a hand as a physician organization representing physicians in designing what that looks like than leave it completely to Congress.
And so, lots going on in that space. Good momentum. But this is a huge problem, and it's no quick fix. We've been working at it for some time. We have good consensus across medicine. Really pleased with the direction that it's going, but it's going to take continued work.
Unger: Todd, thank you so much for all of that context. I think that'll mean a lot to the folks out there that are listening to understand the priorities and what's happening behind the scenes. For people that want to learn more about our top priorities and advocacy efforts, where do you suggest they go?
Askew: Well, right to that home page, ama-assn.org. We have a lot of resources there. You can go to fixmedicarenow.org also to see a lot of resources on Medicare payment reform. And there's a lot of other resources throughout the AMA website that are available to help physicians become advocates for these issues and for themselves as well.
Unger: I encourage everyone to take a look at the AMA's progress report, which you can download from the home page of the AMA website and join the thousands of other folks out there who have gotten a very important update on where we stand on a lot of the issues that Todd talked about today.
Also encourage you to sign up for the AMA Advocacy Update, a newsletter that will keep you on top of the latest news on the advocacy front. Todd, thanks so much for joining us today. These issues are so important to physicians. We want everyone to know how we are advocating for them.
To support the AMA's work on these issues and more, we encourage you to become an AMA member at ama-assn.org/join. That wraps up today's episode. We'll be back soon with another AMA Update. You can subscribe to new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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