Advocacy Insights: Across the country, how are states taking up key health care issues?

A few months into the 2025 state legislative sessions, how are the key issues of prior authorization, scope of practice, and physician wellness playing out? What themes are emerging and how are they different than those of previous years?  

Watch this webinar to hear from a panel of AMA Advocacy Resource Center attorneys about how the AMA is working with national, state and specialty medical societies to address these key legislative priorities. What does the current landscape look like? How is state-level advocacy done most effectively? What tools and resources does the AMA offer to help states and specialty medical societies confront these issues and improve patient care in their home states? 

Host

• Bobby Mukkamala, MD, president-elect, AMA 

Speakers

• Daniel Blaney-Koen, senior attorney, Advocacy Resource Center, AMA 
• Emily Carroll, senior attorney, Advocacy Resource Center, AMA 
• Kim Horvath, senior attorney, Advocacy Resource Center, AMA 

Dr. Mukkamala: Hello and thank you for joining us this afternoon for our latest in the AMA Advocacy Insights webinar series. I'm Dr. Bobby Mukkamala, president-elect of the American Medical Association and an otolaryngologist in private practice here in Flint, Michigan. It is great to be with you all today for this important discussion about the issues physicians should be paying attention to as state legislative sessions are underway this year. 

So with so much attention in 2025—while so much of it is being paid at the health policy changes at the federal level, it's the issues unfolding in the states, such as scope of practice, prior authorization reforms, physician burnout and wellness, that are among the most important issues physicians and patients are facing. And that's why they remain among the AMA's top advocacy priorities. 

But with each new year, while there are endless challenges, there are also opportunities to engage in solutions that can help us create a better health system. And that will be the focus of our conversation today. The AMA has a number of tools, resources and support to help state medical associations and national medical specialty societies confront these challenges and improve patient care in their home states. 

So throughout the next hour, we'll be discussing the trends we are seeing in states across the country and giving you an idea of what effective state-level advocacy looks like. To help us, we have three experts from the AMA's Advocacy Resource Center—the ARC—which is the hub where we collaborate closely with national, state and specialty societies to influence laws and regulations to best support physicians and patients and help shape the health care policy landscape. 

I'd like to welcome three senior attorneys from the ARC, Emily Carroll, Kim Horvath and Daniel Blaney-Koen, who specialize in different health care policy issues for the AMA. And I will just add that having experts in their work like these three, let me or let us as doctors stick to our jobs, our passions to take care of our patients. We do what we love and these folks do what they love, which is improving health care in this country. So thanks, guys. 

They're going to provide us with an inside look at these issues and the states where progress is being made. And I want to make sure that we have enough time to discuss these important issues and answer the questions you have, so let's get started. I'd like to start by asking each of you to talk about the trends you're seeing across the country on the key issues that we're talking about today—prior authorization, scope of practice and physician wellness. 

We're about halfway through some state legislative sessions, while others are almost done, and a couple are just getting started. So how are state legislators addressing these issues now? And are there any big surprises or changes from how legislators may have been looking at these issues a year ago? Why don't we start with you, Kim? 

Horvath: Thanks, Dr. Mukkamala. And thank you for the pleasure to be here today and talk to physicians and health leaders across the country on these important issues. And you're right, a lot of the sessions are about halfway through this year. But we wanted to start with a little bit of an overview of where we are. 

So right now, most of the states are currently in session. Three states have adjourned for the year, including Wyoming, Utah and Virginia. And Louisiana will begin their session April 14. So they start a little bit later than everybody else. Most of the states are going to wrap up their sessions by the end of May. 

About a dozen more will finish it up in June. And then several states do continue, over the year, to have sessions. So right now is really crunch time in a lot of the states. And I also think it's important for everybody out there to understand that, with the exception of a couple of states, we're at the start of a two-year legislative cycle. 

And what this means for what we'll be talking about today is that if legislation has reached a certain point in the legislative process this year, in many states, that legislation will carry over to the 2026 legislative session. And I think it's also important for everybody to note that the procedural aspects and everything vary so much by state. And so we really rely on those at the state level and the state medical societies to help us best understand all of that and those unique features in their states. 

So to talk about scope of practice specifically—I'll start there—this is an issue that continues to be one that state lawmakers want to address. It comes back year after year. And I think it's really unique among the other topics that we're going to talk about today—prior authorization and physician wellness—and that our focus is really defeating bills. 

And so that puts us in a little bit of a unique position. And we continue to oppose the inappropriate scope expansions, including legislation that would allow physician assistants, nurse anesthetists, nurse midwives, nurse practitioners, and such, to practice without any physician supervision or collaboration or oversight whatsoever. So we continue to try to oppose those bills and work to oppose those bills. 

We also oppose legislation and work very hard to oppose legislation focused on pharmacists and specifically legislation that would allow pharmacists to diagnose patients based on the results of a test and then prescribe medications to patients based solely on the results of that test, without any sort of physical examination or any other information about that patient. We're also working very hard at the state level and seeing a lot of bills focus on naturopaths, including bills that would allow naturopaths to be licensed in a state, as well as the ability to prescribe medications, including controlled substances in some states. 

And then finally, we're focused on optometrists who continue to look to the ability to perform surgery in states and then psychologists prescribing legislation as well. And I think across the states, we often see similar bill language because the nonphysician advocacy organizations work to have similar language in states. So we are able to see that legislation or that language pretty be clearly. 

But I think the biggest change we're seeing this year is the volume. This includes legislation that was defeated in previous years that comes back again, year after year. We're also seeing that in those states where they may have expanded a particular nonphysician scope of practice in prior years, we often see that nonphysician come back in future years, looking for further scope expansions. And we're also seeing other nonphysicians will see that a state—that some nonphysician was able to expand their scope in that state. 

And then they come in, other nonphysicians come in, with their own legislation. So we are seeing a lot of bills this year and tracking a lot of bills across the country on scope. 

Dr. Mukkamala: Thanks, Kim. Emily, there's a couple of other ones, prior authorization and physician wellness. You want to give us an update? 

Carroll: I can take the prior authorization, absolutely. So in prior authorization this year, I've seen, really, a broad range of bills in terms of their scope. We've seen some really big, comprehensive prior authorization bills that target a number of issues. And then we're seeing a lot of smaller bills that target maybe one aspect of prior authorization. 

And those may be part of a state medical association's multiyear plan to implement prior authorization reform. But I think, generally, a couple of themes we're seeing across the board, there seems to be a recognition that we have to address the delays in prior authorization. The AMA would say 24 hours for urgent care and 48 hours for nonurgent care is the gold standard. 

And we're seeing a lot of movement towards automation of prior authorization. There's new federal standards for both the drugs and medical services benefits, and we really support aligning state requirements around automation with those. I think we would point out that automation alone is not a whole solution in and of itself, but it certainly is part of the prior authorization solution. 

There also seems to be a lot of momentum around reducing the volume of prior authorization. I think this is what we talk about a lot, right? The volume, everything is being required to be prior authorized. And so some of the solutions that we're seeing include exclusions for certain types of services, so excluding treatment for substance-use disorders or cancer care. 

We see some states remove prior authorization for primary care or for generic medications. We're also seeing an effort to really reduce repeat prior authorizations, especially for patients who have chronic conditions or long-term conditions, so that they're not going back to their physician to get prior authorization for the same treatment, for the same condition multiple times a year. 

And then we continue to see a lot of gold-carding proposals, which are that idea that if you have a high rate of approvals from an insurer on a particular service or a particular group of services, maybe you shouldn't have to be doing prior authorization repeatedly for those services. So you should get a gold card or an exemption for that. And then we're also seeing a lot of states adopt requirements and consider requirements around the qualification of the reviewer on the plan side. 

So we would say, from the AMA's perspective, certainly, that reviewer on the plan side should be a physician of the same specialty, licensed in the same state, and have experience treating that condition in order to be making that medical necessity determination because, really, that is the practice of medicine. So we're seeing a lot of states toy with those qualifications and tighten up who can be making those decisions. 

We're seeing a lot of efforts around data collection, so either having insurers post on their website statistics around their prior authorization approvals and denials and wait times and things like that. And then we're seeing a lot of states move away from even just having the individual payers posted on their website and have that data reported to the insurance commissioner so we can see trends and really make more targeted reforms. 

I think a lot of lawmakers are interested in getting their hands on that data and really seeing how they can make specific improvements that relate to their state populations. We're seeing a lot of continuity of care, so that idea, as you switch plans, maybe you don't have to start all over on a prior authorization, have that 90-day period where you can stay on your medication and not lose function or not lose health as a result of having to do a new prior authorization. 

And then, certainly, a lot of bills around transparency, so transparency on reasons for denials, transparency for the appeals processes, transparency on the criteria that's used to make these determinations. So, yeah, a lot of movement around that level of transparency. And then finally, something a little bit new. Last year, we saw California enact a bill related to the payer use of AI in prior authorization determinations or medical-necessity determinations and making sure that if an AI tool was recommending a denial that a physician was in the loop, that a physician was the one ultimately making that denial rather than the AI tool. 

And this year, we're seeing a lot of states glom on to that idea and start introducing bills that would keep a physician in the loop when it comes to AI-tool decisions. So we're certainly supportive of that, and I think we're going to see a lot more activity in that AI space. 

Dr. Mukkamala: Thanks for that answer. You guys know, I've had a recent diagnosis of this brain cancer. And the medication that I happen to be recommended to take literally costs $900 per day. And so I completely get why prior authorization is required for something that's $200-plus thousand. 

The downside of that is it's prior authorization every 14 days for the rest of my life, for years to come. And so there's rightsizing of prior authorization in multiple aspects, I think, the number of days that we get authorized for. But that same sort of criteria for somebody with insulin dependency, that's going to need insulin for the rest of their life, just like I need this pill, when it's not $200 a day—or sorry, $900 a day, there's a rightsizing that needs to be done. So thank you for that update. 

Carroll: Important point. 

Dr. Mukkamala: Daniel, you want to talk to us about physician wellness and what's up that way? 

Blaney-Koen: Sure. Thank you, Dr. Mukkamala. Unlike the 94 different aspects of scope of practice and preauthorization and payer issues, what we're trying to do with physician wellness in the legislative standpoint and on an advocacy standpoint is really focused on just a couple of key things. One is we want to remove stigmatizing and inappropriate questions on physician licensing applications and credentialing applications and anywhere else that a physician, or really, any health care professional has to fill out. 

And what I mean by that is, on these applications, physicians and others are asked to disclose if they've ever had any treatment for a mental health issue, if they've ever had any treatment for a substance-use disorder when there is no current impairment. And that's the distinction we try to make in our advocacy. We want to ensure that there is safe practice. 

So if there is a current impairment, that should be disclosed to a hospital health system or licensing board. But if there is no current impairment, we want to encourage physicians to not have the fear that getting treatment will have to be disclosed. And so what we're doing on an advocacy front is, one, working with regulatory boards, which we'll talk about in a little while, to change the questions, working with them directly, and also trying to enact state legislation prohibiting these types of questions. 

And that type of legislation, we've only started doing that for a couple of years now. And we really want to give a shout-out to the Medical Society of Virginia for being the first one to do it. And one of the trends we see is other medical societies and other state legislatures saying, we want to do that, too, because we care about our workforce. 

We don't want our physicians to be unsafe. And in fact, we want our physicians to be well. We don't want them to fear getting treatment. And so the legislative and regulatory trends that we're seeing are everybody's going in the right direction. Nobody is fighting against us. 

And so it's a question of awareness. A couple of years ago, there were only about 20 medical boards where the licensing applications were free of stigmatizing language. We're now at about 34. A couple of years ago, there were only about 50 or 60 hospitals and health systems where their credentialing applications were free of stigmatizing language. 

Now we're on our way close to 600. And so the trends are only going one way. And this is the kind of thing that myself, Emily and Kim—we work directly with states to try to provide these best practices directly so states can implement them. 

Dr. Mukkamala: Thanks, Daniel. And yeah, absolutely. I think it's one of those things that we're going in the right direction. The faster we get there, the less physician burnout we're going to have. If physicians have to deal with this measurement that's based on old data, it's just going to make one more thing that would make us leave our profession earlier. And just consequences—worse patient care. 

And we're already challenged by that. So thank you for that. I'm just going to jump to a comment about prior authorization that we've already had in the question box. And it said, presuming that we're aware about the adverse outcomes associated with prior authorization—and I'll just share with this person that, yeah, when I gave testimony in Michigan about prior authorization being a problem, I took with me a patient that had stage 1 tonsil cancer, before we asked for the PET scan that was required to figure out what treatment was needed. 

While waiting three weeks for the PET scan, the patient went from stage 1 tonsil cancer to stage 2 tonsil cancer. They developed a metastatic node. And I took that patient with me. And it was amazing how effective just the story of an individual patient was relative to national statistics in convincing the people at the Senate hearing that, wow, yeah, this is a problem. 

So, absolutely, we share that information with our lawmakers. So just the question in general about our interaction. So how does your team work with the state medical association to urge state legislators to make crucial reforms in these areas? So how does the AMA fit in with the medical association when the person that we're addressing is the state legislator? What is that interaction like? Emily, you want to tell us? 

Carroll: Sure. I know Kim and Daniel have more to add. But I'll start by saying that we really try and be a resource for the medical associations. That may look a little bit different in every state. The medical associations are the ones who know the politics in the states, the legislative strategy. 

But we can offer them a broad perspective—what other states have done, what's maybe happening federally and nationally that they can build on. I'll give you just a quick example on prior authorization. Obviously, there's so much constant activity in the states and federally that it would be really hard for one state to keep up on that national activity and to keep up on the trends or successes that other states have had. 

So I can provide them with information on prior authorization bills that have passed in other states, how they were framed, what groups were engaged and supportive and what tactics the plans used to fight those bills. And we try and develop the resources so that they have turnkey solutions when they're having these conversations. For example, last year, we developed a new issue brief on prior authorization on how states can use the new federal rules on prior authorization to promote reform in their states because we knew that states were hearing from lawmakers and the plans that there was no more need for state legislation on prior authorization because the rules at the federal level had fixed it. 

And so we developed an issue brief that states were able to quickly use and say, oh, hey, that's not true. We can build on our federal wins, but state legislation is really important and here's why. So resources like that to help them in their efforts. And then we often engage directly on legislation if it's going to work in a particular state, if that's helpful to them. 

So we write letters of support for legislation. We can testify. We submit testimony. And then we always are reviewing bills and tracking bills and providing input to the medical associations as they go through their sessions. I'm sure Kim and Daniel have things that I've missed. 

Dr. Mukkamala: Sure. Daniel, you want to give us your impression about the intersection between state medical societies and state legislators? 

Blaney-Koen: Sure. Let me give you an example—Colorado, this year. So we have a series of best practices in an issue brief that I'll pop into the chat in just a few minutes. But a series of best practices that highlights certain pieces of other states that have enacted laws to prohibit these types of licensing questions that require disclosure of past treatment or diagnosis of mental health or substance use disorder. 

And so we talked with medical societies and specialty societies about the information in the issue brief. Well, in Colorado, the state chapter of the family physicians and the state medical society, the state emergency medicine chapter and the state psychiatric society all got together, and using that issue brief, went ahead and decided, we need to amend state law to go ahead and remove ensure that the licensing applications throughout the regulatory boards are free of stigmatizing questions. 

And so the AMA worked directly with our partners in the state, in Colorado, to produce an amendment. And that was there's a legislative champion in Colorado, a couple of legislative champions. And then working together, there was a bill that was introduced. And part of the aspects of that is that we also identified physician champions within the state of Colorado to develop testimony. And so they testified at a hearing. 

We identified a medical student who wants to be able to ensure that if she seeks treatment or her colleagues seek treatment, they won't fear disclosure and potential professional repercussions for seeking care for a mental health issue. And so all of that combined together. And that bill passed the House. 

It's awaiting hearing in two weeks in the Senate. And we'll take the same approach, negotiating behind the scenes with people who might have some concerns and then testifying. The AMA also testified at that hearing and will testify directly before the legislature on the benefits of that legislation, provide any additional information, data, what have you, about what's happening and also provide Colorado—and this was an important point in Colorado. 

We've had so much success in states in doing this. Colorado doesn't want to be left behind. They want to be known as a place where it's safe to practice medicine. And so that's been an important point. So everything coming together, it's one small microcosm in Colorado, how AMA resources work behind the scenes, partnership with our state and specialty societies. 

And really, relying on medical student and physician advocacy has been successful so far in the House. And we hope it's successful in the Senate and the governor will eventually sign it. 

Dr. Mukkamala: Thanks, Daniel. And Kim, it's pretty clear that scope of practice is such a critical, local-level thing that varies from capital to capital. So what are your comments or thoughts about the teamwork between what AMA can do to help the state medical society influence the legislators' process on looking at scope of practice stuff? 

Horvath: Yeah. So, yes, scope is a priority for a lot of the state medical associations, just as it is for the AMA. So they are all over it. And as Emily and Daniel both mentioned, we provide a ton of resources, write letters, draft testimony, provide best practices and other specific date solutions, reviewing legislation and providing some recommended amendments or language that they might work on, as well as talking points that they might be able to use to refute arguments that are made by proponents. 

Because we've often heard those same arguments in other states. One of the things I think is particularly unique about the scope-of-practice space is the work that we do through the Scope of Practice Partnership. And this is something that began back in 2007. It's comprised of more than 110 medical associations, including the state medical associations, including national specialty societies, the AMA and the American Osteopathic Association. 

And really, our goal of that is to be able to provide additional resources, funding, as well as data and other type of in-kind resources to support our colleagues at the state level. And it is a very actionable way in which we do get involved at the state level and really help our colleagues get things across the finish line. 

Dr. Mukkamala: Thanks, Kim. So as is the case with nearly all of our advocacy, these issues impact more than just physicians. The consequence of this, the most important consequence is that on patients. And so can you guys talk a little bit about how your team works with other organizations and why this is important? Daniel, you want to go first? 

Blaney-Koen: Yeah. Other organizations are key. We want to build as much support for the work that we do as possible. And I want to emphasize another thing, that physicians don't work in hypothetical situations. The patient that had stage 2, unfortunately grew to stage 2 tonsillectomy, that patient didn't need hypothetical care, the same way that other organizations need to understand that we're not just doing this for the sake of policy. 

We're doing this because it has real patient impacts. So for example, other organizations that people on the call probably have never heard of, but groups like the national—for wellness issues, groups like the Federation of State Medical Boards, they're the national governing association for every state medical board. The AMA and the Federation of State Medical Boards, we're on the exact same page when it comes to physician wellness issues. 

And we want every state medical board to adopt these best practices. So we work directly with the FSMB to go ahead and make presentations, to put articles together. People may or may not see them. So we work with other organizations, such as the Joint Commission. Any physician on the call probably has heard of the Joint Commission. 

You may have heard of other alphabet soup groups like NCQA or URAC. These are credentialing verification organizations. They agree with our recommendations. And so when we do advocacy to state legislatures and state regulators and we have the support of these other organizations, it lends credibility to the solution. 

Because ultimately, the solutions are those that directly help patients. And in the physician wellness case, it directly supports physicians getting care. The top reasons physicians tell us that they don't receive care is because their fear that it's going to have professional repercussions. Physicians fear that disclosure of past treatment of a mental illness when there is no current impairment is going to be an anchor on their career. 

They're going to be judged by their colleagues. And so, we want to remove as many barriers as possible so that physicians can get care if they need care. And these other organizations, we know that they talk to people in places that we don't go to. And so that's why we work with all of these alphabet soup organizations to go ahead and build as broad a coalition as possible. 

Dr. Mukkamala: Thanks, Daniel. Emily, as it comes to prior authorization, tell us about who else we work with to try to accomplish that. Because the consequence is so high for our patients. 

Carroll: Yeah, absolutely. I mean, on the issue of prior authorization, I think the biggest pain point for physicians is the harm it has on their patients and the intrusion that prior authorization has in the patient-physician relationship. So there's just a natural synergy with so many of the national patient organizations, and we work really closely with them. 

I think all the reforms I mentioned earlier, you can see the theme is relieving some of that patient harm. So this led to the formation of some really successful collaborations between state medical associations and patient organizations, the local chapters of some of these national groups. And we've spent a lot of time here at the AMA, over the last several years, meeting with national patient organizations, listening to their concerns on the issue of prior authorization, vetting some of our solutions, and making sure that we're aligned wherever we can be. 

And so we've helped create a framework here at the AMA that we can then—as a state medical association decides to take up the issue of prior authorization reform, we can then help say, OK, these are the organizations that are looking to be active on this issue. Let's activate either a formal coalition, which several states over the last year, a couple of years, have done, and created websites with patient organizations, and really shown to legislators how widespread the problem is and how much impact it has on the patient community—and then we also have states that work very informally with the patient coalitions, whether it's doing just a sign-on letter or something like that. 

I think that relationship with the patient and consumer organizations over the years has really led to successful reforms. I can't even think of legislation that has passed in the last several years where it hasn't been part of a joint effort between the state medical association and the physicians and the patient groups. So really critical relationship there. 

Dr. Mukkamala: Thanks, Emily. And Kim, any thoughts about how—beyond physicians, other groups that help with their scope of practice efforts? 

Horvath: Yeah. Again, scope is a little bit different here, right? Physicians are often the leading voice in opposing inappropriate scope expansions. But I will say that the patient perspective—and it's good that I'm going after Emily—because the patient perspective is really critically important. And so we do bring that perspective into our advocacy. 

And we can do this through some of the survey work that we've done. We've interviewed and done a number of national surveys of voters and patients across the country. And from those, we know that patients want and expect physicians leading the health care team. And we also know from those that they want physicians being involved in the medical diagnosis and treatment decisions for their health care. 

So we make sure that lawmakers know this as well. So that's one way that we do this. We also make sure that patients are informed. And so that's another angle of our campaign is there's a lot of different health care professionals. So Daniel mentioned the alphabet soup. There is an alphabet soup, a lot of different health care professionals. 

And it can be incredibly confusing to patients, especially in a hospital setting or somewhere where they're not actually making an appointment and know who they're going to see, but where they have different health care professionals coming into the room. And whether they're the patient themselves or a member of the patient's family, just having the information and feeling empowered to ask—somebody walks in with a white lab coat or scrubs, are you my surgeon? 

Are you an anesthesiologist? Are you a nurse anesthetist, a physician assistant, nurse practitioner? Who are you? What member of you of the health care team? And so just giving information, empowering them to feel like they can ask that question. And that response, then what does that mean? 

What is the difference in education and training, for example? And so that's another aspect of the work that we do, is just patient education and making sure that they feel empowered to ask questions and have the information at their fingertips. 

Dr. Mukkamala: Yeah. And I'll just mention—this is the oddest example of working with another organization—but when we had a potential expansion to independent nurse practitioner work here in Michigan, it was a nurse practitioner that then became a doctor that came to talk about why it was that she pursued this career and why, looking back on it, there's no way she would function independently. 

And so technically, she was in our group. But before she was in our group of physicians, she was in those people that we were having a conflict with about taking care of patients. And then she's the one that basically said, I'm glad I became a physician because now I can take care of my patients better, independently. So the next question I'll ask Emily. 

I know that you all also spend a great deal of time working with national policymaking organizations to try and bring attention to some of our advocacy goals. So why is that important, Emily? 

Carroll: Well, I think they are just a critical piece of the puzzle here. And as we work with these national policymaking organizations, we plant seeds that help feed into the state-level activity—best ideas, best practices that we share with these groups. Often, these national policymaking organizations may develop model legislation or model regulation. 

And so we try and influence that activity so that when it makes it into the individual states, it contains some of our policies and positions. For our state health insurance work, groups that represent interested legislators, like the National Conference of Insurance Legislators and the National Conference of State Legislators, are really important organizations for us to work with. We regularly attend their meetings, offer presentations, share resources with these groups. 

And then, also, in this health insurance space, the National Association of Insurance Commissioners plays a big role in insurance policy. Insurance regulators, they not only implement and enforce the laws that we're talking about passing here today on health insurance, but they also are involved in the development of legislation. And often, in the states, the NAIC develops its own model legislation and model rules. 

They offer model bulletins. So we work really hard to influence the activity there so that when those models come to the states, they're really reflective of our work and of our priorities. And I know Daniel works with a lot of these groups too. 

Dr. Mukkamala: Yes. So, Daniel, speaking of regulators, I know that you are working hard to impact regulations related to physician wellness. So can you talk to us more about that interaction? 

Blaney-Koen: Yeah. So I mentioned earlier we've gone from about 20 states that have removed invasive questions to now we're at about 34 states that have removed. That means we're getting there. I don't do math very well. I'm a lawyer. But I think that means we only have about 15 or 16 states to go. 

This is something that doesn't necessarily require legislation, but it requires commitment. And so we can't necessarily advocate for regulatory boards to show the commitment to their licensees to support physician health. So that's why we work with two important groups. I mentioned the Federation of State Medical Boards—critical partner. 

The Federation of State Physician Health Programs, another critical partner. But one of the most powerful groups that we've developed a really close relationship with is the Dr. Lorna Breen Heroes Foundation. And some people on the call might know who they are, but this is the foundation that was started by the tragedy during the early days of COVID, when Dr. Lorna Breen, an emergency medicine physician in New York, died by suicide as a result of all of the stress and burnout. 

And she didn't feel like she could get help. And so it's remarkable what's happened with the Breen Foundation, where we work together to talk directly to medical boards. We ask medical boards—and this is something that still blows me away. We ask medical boards to share their licensing applications with us and many have, but some don't. Some don't want to do that. 

And so with another one of our colleagues in the Advocacy Resource Center, we sent FOIA requests to those boards to get the applications so we could do direct advocacy. Now, some of the medical boards, I'll say, Dr. Mukkamala, they didn't appreciate the AMA's direct advocacy to stop asking questions that were stigmatizing about mental health and substance-use disorders. 

But the AMA continues to ask those questions. We work behind the scenes. We don't call anybody out for doing this, but we want all of the regulatory boards to meet the same, consistent national best practices that support physicians from getting the care they need when they want to receive it, and at the same time, balance that with their statutory obligations to protect patient safety. 

And so, like I said, 34 have done it. The 16 or so that haven't done it, we want to work with them. They know that they need to do it. And so we're going to continue to work with them until every state in the country has met that national best-practice consistency standard. 

Dr. Mukkamala: Thank you. So, Kim, what wins have you seen in these areas? And are you seeing that these wins are shifting conversation happening in other states? 

Horvath: Yeah. So in terms of the wins this year, it is still early. I'm a little superstitious, and I don't like to count anything as a victory, especially in the scope of practice space, because, obviously, we're either trying to defeat bills or amend legislation. So I don't like to count anything as a win until that last gavel has been struck and the session is officially over. 

But we are seeing some good trends so far this year. And I think, really, it is a testament to the work of the people that we get to work with and have the privilege to work with every day at the state medical association. Their lobbyists or government affairs staff are amazing. But it's also the physicians, the physicians who take the time out of their busy schedule to talk to lawmakers, especially a bill is coming up for an important vote or they're going down to the capitol to talk with them or testifying on a specific bill. 

All of that is really important. And so I think that that is the key to ongoing success. And from an overarching level, the work that the team here at the AMA does, and the AMA as a whole, I think we have been overarchingly successful. And just if I can point to a number from last year, we had over 200 victories at the state level. 

And again, this is, again, working hand in hand with our colleagues at the state level. But on all of the issues that we work on, over 200 victories. So we continue to work on these issues. But there are significant victories along the way. 

Dr. Mukkamala: Thank you. I'm going to skip ahead just to make sure we get to cover enough questions. Then we can go to some of the Q&A. But you've all been working on these issues relentlessly, year after year, to get these wins in any given year. And it's not about sending one letter, or partnering with one organization, or reaching the finish line and then we're done. It's not a victory that's permanent. 

And so in advocacy, there's always more progress to be made. And the AMA has been at the forefront of this, advocating on behalf of patients and physicians. So can you tell us about playing the long game? Is there anything strategically that we should do to not just win this single thing, but the entire thing? So, Emily, what are your thoughts about the one-year victory versus changing the trend so the next generation of physicians and the next generation of patients have a safer, better place to practice and to be taken care of? 

Carroll: Yeah, it's such an important point, Dr. Mukkamala, and I think one that we have to remember sometimes, ourselves, that we have to play the long game. Even in the states where things might happen a little bit faster than they have been in DC, it can take years to really lay the groundwork for reform, build those coalitions we've been talking about, educate lawmakers, get the language right. 

When I started working on prior authorization reform many, many years ago, all legislators really wanted to talk about was a standardized form, so standardizing the question set, which is a great solution, but it wasn't a comprehensive solution. They didn't understand what prior authorization was. Patients didn't understand why they weren't getting their care. 

And so the education that had to be done, the storytelling that had to happen, the connecting the dots between one person's personal experience with a health insurer and the need for systematic reform, that had to be done, and that had to be discussed, and that takes time. So obviously, as a result of all the hard work of the state medical associations, I think we're now in a place where we're talking about volume reduction. 

We're talking about continuity of care, qualified reviewers, timely responses, and meaningful, comprehensive reform. And groups are working that into their agendas as we discussed. And sometimes, the progress isn't totally quantifiable. You can't necessarily measure it as an obvious win, but I think it's progress nevertheless. And like you said, it's really important that we're playing that long game. 

Dr. Mukkamala: Thanks, Emily. Daniel, any thoughts about the long game as it relates to physician wellness? How do we get it to be an environment that physicians are happy to practice in? My mom's a retired pediatrician. She worked until she couldn't work anymore. 

There was never a burnout cause for her to even think about stopping her practice. How do we go backwards to that time where physicians work until they just can't work anymore, as opposed to, you know what, I got to get out early? 

Blaney-Koen: Yeah, that's a great question. And I'm glad you followed your mom's footsteps there, Dr. Mukkamala. I think the long game, we have these legislative wins. And then for the wins, then they have to be implemented. So the regulatory agencies need to do more work—as Emily mentioned, the National Association of Insurance Commissioners. 

I work with regulatory boards. We work with a number of others. But we work closely with the regulatory agencies to actually implement the laws. These laws don't enforce themselves. And so we want to then go ahead and have these regulatory agencies and others actually communicate what the laws do. 

We find, in the wellness area, just because a group or a hospital health system or state removes these questions from applications, that doesn't mean anybody knows about it. I'll give you one story. There's a large health system in your state, Dr. Mukkamala. They were one of the first that we worked with. 

And everybody in the C-suite worked really hard, and we were all on the right page. And then they found out a month later that they forgot to tell the IT people to actually make the change. And so when they realized that, it got taken care of pretty quickly. But if you don't tell anybody about the win, you don't tell anybody about it, or the regulator doesn't actually enforce the law, then the effects can be much more limited. 

So the long game also involves enforcement in many cases, and it involves communication. And so those are some other areas that we take advantage of in the long game. And the other thing is awareness. Emily and Kim talked about that. Everybody's very aware of these issues. 

And with physician wellness and these work on credentialing applications and questions and removing stigmatizing language, even though the Americans with Disabilities Act has been around for a long time, nobody really applied it in this manner, as it goes to licensing questions. And so we take a look not only at what the requirements are, but we have to make sure that everybody is aware of how to implement that and make changes. 

The awareness and communications takes a little bit more time, but that's what we also do. Dr. Mukkamala, let me turn the tables a little bit on you. As a physician advocate, you have been active—certainly have been active with the AMA. But you've testified and had meetings in state legislature in Michigan. 

Can you tell us a little bit about what you have learned and the resources and other things that you've done at the state level and how you've worked with your state medical society that can shine a light on what just us lawyers are talking about here? 

Dr. Mukkamala: Sure, yeah. I can't even count how many times I've heard in my 25 years of practice and advocacy work where a lawmaker has said, when we go there to testify, that we've never heard from many doctors on this issue. It's the first time they're hearing from—and sometimes, I think that's just the way they try to wiggle between two different opinions. But sometimes, it's a reality. 

And it was just so frustrating because I knew that we contacted many of them. But if it didn't stand out from their perspective, I have to think that they heard a lot from those on the other side of any particular issue, so whether that was an insurance company, whether that was a nonphysician health care provider. And so for those reasons, I think that physician advocacy is critical. 

As frustrating as it is to see, for example, in Michigan, my home state, in my practice, there were two times that we convinced the lawmakers that, you know what, if we're going to put somebody to sleep, if I'm going to put a kid to sleep to deal with their airway issue, I want an anesthesiologist available and not just a nurse anesthetist. And two times, the lawmakers 100% agreed. And they insisted that anesthesiologists be part of that anesthesia team. 

The third time it came up, we lost. And now we have independent function of nurse anesthetists. The science didn't change. But it's just who they hear from. And it's a new group of lawmakers, so three different classes of lawmakers over the course of the past 25 years. The first two classes decided that this is important, we need to maintain physicians' presence there. 

And then the third class that happened to have three nurses within that class of lawmakers decided that it wasn't something that was critical. And so I think it's important to share the stories of what prior authorization is like, what it does to my patients with the head and neck cancer so they can hear from physicians what it's like in our operating rooms, what it's like in our offices, taking care of patients. It's critical that we present that to them because that's where the rubber meets the road. 

And the more we can take it down from a theoretical, academic conversation to, this is what's happening to your constituents, to our patients, to our neighbors, I think that's when they start to listen. So it looks like we've got just about 10 minutes left. And so why don't we go to questions, guys? 

I'll read them to you, and then we'll either assign them or—and this one looks like maybe Daniel first. So in addition to prior authorization and the wellness act, please address what the AMA is doing to combat attacks on truth, vaccines, and other important public health issues. What else can we do at the state level? 

Because this is a critical issue for physicians and our well-being. Knowing that we know the science but being confronted with these headwinds, how do we help physicians take better care of their patients because of this? 

Blaney-Koen: Yeah, I'd say for the start, public health issues are handled by another one of our colleagues here. I work a lot on mental health and substance use disorder issues as well. And one of the things that we talk to our state medical societies and other partners about is we always want to highlight the research. We always want to highlight the science. 

You made a great point, Dr. Mukkamala, that the science hasn't changed. And so, when it comes to substance use disorders or the treatment of opioid use disorder, we want to make sure that we're using the best evidence-based science. One of the things that Emily and I work on together is removing prior authorization for medications for opioid use disorder. 

The evidence is clear that MOUD is the gold standard of treatment. And if there is prior authorization of that at the pharmacy counter, there's a chance that that patient will leave the pharmacy counter and potentially use again because they didn't get their medication and potentially die. So we highlight what the real-life consequences are. 

And that's just one important public health issue. And by staying true to what the science is and being clear about what the science is, that's how we address at least that one aspect of it. And I'd encourage everybody. The AMA has—you know this better than I do, Dr. Mukkamala. The AMA has been very clear about our support for a wide range of public health issues. 

I wouldn't pretend that the AMA website is always easy to navigate, but the issues are there, and they're clear about AMA support for those issues. And so, I would say rely on the information from trusted organizations like the AMA to provide that information back to state legislatures. 

Dr. Mukkamala: Thanks. And I'll just mention a little thing that I've learned and that there's so much on the AMA website, to find a particular answer to a question is somewhat difficult. But that's where a Google search or an internet search really comes in handy. If you type in AMA and prior authorization, you'll see all sorts of our content that come up that way. 

So not having to navigate through our website, but going and clicking something right on the internet search that will take you right there. 

Blaney-Koen: Yeah. And, Dr. Mukkamala, I might also say, every state medical association and every state medical society knows how to get a hold of the three of us. There are now, at this point in our careers—I won't age any of us, but we've all been here a while. Physicians know how to get a hold of us, and we're always available to talk to medical societies, to talk to individual physicians, to talk to medical students. 

We do it on a daily basis. So if there's ever any question on these issues, just call us. We're happy to talk with you. 

Dr. Mukkamala: Thanks, Daniel. Emily, a couple of questions. One might be a quick answer, and that is, will the prior authorization resource that you mentioned be posted? And then also, what state strategies—sorry, it's still moving. What state strategies have been undertaken regarding pharmacy benefit managers, if anything, at the state level? 

Carroll: Great. Yeah. And the resources, absolutely. And this gives me a good opportunity to shout out our fixpriorauth.org microsite, which is a great grassroots resource. You can share your stories there. You can access all these resources and more. 

And our colleagues in our administrative simplification initiatives department do an awesome job of putting all that information out. And I would direct you, also, to the recently released prior authorization physician survey, which is a great resource for some of this legislative work. It really shows the patient harm of prior authorization, the physician harm and the systematic harm of prior authorization with some really good data points. 

So encourage folks to go to fixpriorauth.org. And then on the PBM stuff—I think that was the next question—I think we are very engaged in PBM activity, certainly related to prior authorization. We make sure, in our model legislation, which serves as the basis for a lot of the state activity, that we are not just targeting health insurers, but that the reforms that are included in it include utilization management entities. 

So that would include a PBM or any other benefit manager that really focuses on utilization review, so reforms in the clinical space, the clinical decision-making space there. Then we also work really closely at NAIC to monitor their work on PBMs and engage whenever possible. We have a great drug-price transparency model bill that Daniel has put together that is out there and available. 

And then we do a lot of work with patient organizations on issues PBM adjacent, like copay accumulators and other things like that, where we feel there are some real PBM problems. So lots of work in different spaces on PBMs, for sure. 

Dr. Mukkamala: Thanks, Emily. Kim, what actions are the AMA taking to ensure that patient safety is maintained in the midst of nonphysician practice scope expansion? How do we make our argument in state capitals about patient safety when there's a look at expansion of nonphysicians doing that work? 

Horvath: Yeah. So, I mean, patient safety is at the cornerstone of everything we do in trying to defeat the scope expansion bills. We do have a ton of resources, whether it's issue briefs or geomap series or what have you, summarizing research and data on this topic and really including the importance of patient safety. And I think those are available to our colleagues at the state level. 

A number of these are available on our website as well. But the why we're working so hard to defeat these. And I think it's also why, as I talked about earlier, we also try to educate patients. Because we think it's important that they understand these issues, as well, as patients themselves, and make sure that they are well informed about who is providing their health care. 

Dr. Mukkamala: Thanks, Kim. Daniel, another question here. Have all the invasive questions for licensure certification been modified or eliminated? I know all is pretty much a stretch of a hope, and I know that's our goal. But what are your thoughts about answering that question to this person? Have all the invasive questions been modified or eliminated? 

Blaney-Koen: No, they haven't. Like I mentioned, there are about 15 or 16 state medical boards that still need to do additional work. One of the links that was put into the chat to the Dr. Lorna Breen Heroes Foundation has a map. And that map, if your state is not colored in on that map, your state medical board needs to do work. 

If you would like to join us in helping your state medical board do that work, give me a call. I'm happy to talk you through it, if you want to be the advocate and the champion to do it. I think there are a couple of thousand hospitals. I don't know the exact number—3,000, 4,000 hospitals in the country, at least. 

We know of about at least 500 to 600 that have changed those applications. For the physicians on the call, I would say take a look at your credentialing application. If it asks you to disclose past mental health treatment or diagnosis when there is no current impairment, your hospital system needs to make changes. Again, we're happy to walk you through how you can be the champion to do it. 

And I think Kim and Emily have both mentioned we work with physician champions all the time. In the work that I'm doing on wellness, a lot of the times, we identify these opportunities because physicians come to us and say, what do you think? Does this need to change? 

And we can say, no, you're good to go. You're consistent. This is a national best practice. Or we say, yeah, we think that there could be some improvements here. Let's work with you, your chief wellness officer, to make those improvements. Our goal is 100%, Dr. Mukkamala. And so, we'll keep doing this until we get there. 

Dr. Mukkamala: Thanks, Daniel. How about we do one more question, and then we'll wrap it up because we're getting close to the top of the hour? Emily, we've had trouble at the state level with prior authorization because state legislators have said that they're waiting for federal reform. 

And so, the statement is, we do need both state and federal work on this. But what about the trouble when you're at the state level and the state lawmakers are saying, we're going to wait for the feds. 

Carroll: Yeah, absolutely. We've heard this a lot over the last couple of years, and we're so lucky that our federal colleagues have been able to accomplish some huge successes at the federal level to address a number of the markets, including Medicare Advantage, some QHPs on federally facilitated exchanges, Medicaid. So, there's been some great progress at the federal level, but the state reform is absolutely needed. 

There's a huge chunk of state-regulated plans that need to be, at a minimum, brought up to the federal floor and, if not, go beyond that. And I'll say the federal progress is very reflective of all the work the state medical associations have done over the years. All those reforms that we saw in those two new rules were successes that had happened in the states over the years. 

So that state activity is so critical, both from a top-down and bottom-up approach. As I mentioned, we have that one resource—and I'm happy to make sure that gets out to folks—that shows what has been done at the federal level, and where states can build on it, and why it's so important that they do. So we will make sure that gets shared out. 

Dr. Mukkamala: Awesome. Thanks for those details, Emily. 

Carroll: Yeah. 

Dr. Mukkamala: And thank you to our audience for your questions. And thank you to our panelists for joining us today and helping us take better care of our patients. The AMA Advocacy Resource Center on our website is the place to find these resources—the data points, model legislation—this is not a wheel that has to be reinvented 50 times in 50 states—the white papers and a host of other materials to support you in our advocacy efforts at home. 

And so, I hope you take advantage of these amazing resources. And please join us in the future for the next AMA Advocacy Insights webinar, where we take you inside the most important policy issues affecting physicians, affecting patients, and affecting our health care system. So thank you so much for participating today. Appreciate it.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.