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Featured topic and speakers
Why do prior authorizations get denied? Who is responsible for getting pre authorization? Why is prior authorization so difficult? How long does prior authorization take?
Our guest is American Medical Association President Bruce Scott, MD. AMA Chief Experience Officer Todd Unger hosts.
- The AMA is your powerful ally in patient care. Join now.
- Get involved! Patients and physicians can share prior authorization stories.
- 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).
- Access AMA prior authorization legislation resources and research.
- AMA prior authorization reform and model legislation.
- Stay up to date on AMA efforts to fix prior authorization policy.
- Get your CMS final rule prior authorization questions answered.
Speaker
- Bruce Scott, MD, president, AMA
Transcript
Unger: Hello, and welcome to the AMA Update video and podcast. Today, we're talking about the findings from a new AMA survey about the burdens of prior authorization. Joining us to discuss the survey and how prior authorization has impacted his own practice is AMA President Dr. Bruce Scott in Louisville, Kentucky. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Scott, thanks so much for joining us today.
Dr. Scott: Thank you, Todd. It's a pleasure to join you to discuss this important issue.
Unger: And this survey that the AMA did happens every year, and it looks at the impact of prior authorization on patients, physicians and more. Why don't we just start off by talking about the impact on patients. Dr. Scott, what were some of the key findings in the study?
Dr. Scott: Well, once again, this survey this year shows the massive burden that prior authorization has become, and this year is no exception. One of the key findings in the survey is that 94% of physicians say that prior authorization delays necessary patient care. That alone is bad enough. But we know that the care delays are just the beginning of the problem.
Prior authorization causes issues for physicians and our practices and for our patients. The survey found that nearly one in four physicians say that prior authorization has led to a serious adverse effect for one of their patients. So this process isn't just a burden on the physicians. It's putting the health of our patients at risk.
And worse yet, the delays that result have almost nothing to do with practicing high-quality medicine. More than one in three physicians say that prior authorization rarely or never is evidence based. And that's been the experience in my practice as well. Just one of these issues I've mentioned alone should be enough to know that we need to fix prior authorization. But when you put it all together, it seems clear that this is reform and needs to happen, and it needs to happen now.
Unger: And I know, Dr. Scott, that you're unfortunately all too familiar with the kind of issues that you just mentioned. Tell us a little bit about how prior authorization has been affecting the patients in your own practice.
Dr. Scott: Well, as a practicing otolaryngologist, the demands on prior authorization are significant. Whether it's medications we prescribe, imaging studies we prescribe or surgical procedures, many of these are now requiring prior authorization. It used to be that it was only experimental or unusual or very expensive things, but now prior authorization has become almost routine.
Let me tell you a story about a recent patient of mine. A lady had come in with a tumor growing on the right side of her face in one of her sinuses, right by her eye. We talked about it, we discussed the different options, and together we decided that the right option was a relatively large surgical procedure to remove the tumor. She agreed, and we planned the surgery.
A few days later, a letter was received by myself and by the patient saying that the insurance company had determined that authorization would not be allowed because the surgery was, quote, "not medically necessary," because the patient had not been on an antibiotic and a steroid nasal spray. Now, we all know that the antibiotic and the steroid nasal spray was not going to get rid of the tumor. I had to pick up the phone and talk to the medical director, who quickly agreed that I was right and that the surgery needed to be performed.
Forget about the wasted resources in my office. Think about the patient. Think about the added stress on this patient, who comes to an agreement with her surgeon for a necessary operation and then gets a letter from her insurance company telling her that she could have simply been on an antibiotic and a nasal spray. Well, I picked up the phone, and I talked to the patient, and she understood that the surgery was indeed necessary. But the unnecessary stress upon her is just wrong. Now, I'm happy to report that we did the surgery, the patient's doing well and recovering nicely, and the tumor was completely removed. But this is just one example of the sort of damage that is done to patients by prior authorization.
Unger: That story explains just about everything that we know that's wrong with prior authorization. And it doesn't just hurt patients. It has an impact on physicians, too. I think just hearing you tell that story, it's very clear. What did the survey have to say about it?
Dr. Scott: The survey once again confirms that prior authorization is a huge burden on physicians and our practices. It showed that on average practices are completing 43 prior authorizations per physician per week, and all that time wasted adds up. The survey revealed that physicians and their staff are spending over 12 hours each week completing prior authorization, time that could be better spent taking care of patients. That's almost a day and a half a week of wasted time on this administrative process.
In fact, 95% of physicians say that prior authorization is leading to burnout in their practice and in them personally. Now, we're already in the middle of a shortage of physicians. Imagine if we could transfer even half of that time back to patient care. We simply cannot continue the process where we are, and we can't afford to lose any more physicians to burnout. Not even one more physician should be lost to this unnecessary burden.
Unger: You're absolutely right. And I know every practice is feeling the burden of prior authorization, especially independent practices like yours. Dr. Scott, can you tell us more about the impact that it's having on your team right now?
Dr. Scott: Well, Todd, I see a patient, I listen to their history, take a thorough examination, review any imaging studies or data that they have brought with them or that's been performed, and then together we come up with a plan. And unfortunately, many of the times my staff has to get on the phone and wait for 30, 40, sometimes an hour to get an answer from the insurance company as to whether they will approve the procedure or the imaging study or even the medication that we've decided is right for this patient.
Sometimes I've got to pick up the phone and talk to them as well. Now, when I do pick up the phone, rarely am I talking to a physician on the other side. And most of the time, they're not an otolaryngologist. I jokingly say, sometimes they can't even say otolaryngology. It's not unusual for me to have to explain the anatomy to them of the procedure that I want to perform.
My staff will tell you that this is a major source of frustration for them. And I can tell you, my colleagues tell me that our practice is not unique, that prior authorization is one of the leading causes of frustration for the physicians, for our staff, and for the patients. They want the medication, the imaging study, the surgery that they and the physician have determined is right for them. And many times, they simply don't understand this whole process of the approval by their insurance company.
Unger: Well, it's clear that prior authorization needs to be fixed. And thankfully, there's been some progress on that front. Dr. Scott, can you tell us about that?
Dr. Scott: You're right, Todd. Over the last few years, the AMA has made significant progress in fixing prior authorization at both the state and the federal level. We've been working closely with state medical associations to make the case for reform in their state legislatures using AMA model legislation and other resources like the survey we've been discussing. And over the last couple of years, we've seen major victories in Vermont, Colorado, Illinois, Wyoming, Arkansas, District of Columbia, just to name a few.
Several states also have pending legislation coming up with new laws that will hopefully be able to continue this momentum. Even now, the AMA is working with numerous states to lay the groundwork for prior authorization in this next year's legislative session.
Meanwhile, at the federal level, we had a big win back in January. The Center for Medicare and Medicaid services, CMS, issued a final rule that finally right-size prior authorization for Medicare Advantage plans and other government-regulated plans. As part of this, health plans will be required to offer an electronic prior authorization process that integrates with the EHR. Can you believe it that right now we're still using fax machines to send in the information for many of our prior authorization?
These changes are tangible. They will go a long way to reducing the burden for physicians. In fact, CMS's own estimates are that this will save $15 billion for physician practices over the next 10 years. Just imagine how big of a problem this is when it's spread across all of health care. This is a tangible change that will help reduce prior authorization, but the AMA is not stopping there. One of our goals is to fundamentally change prior authorization. We need a comprehensive fix. This includes reducing the overall volume of those procedures and medications and surgeries that require prior authorization, improving transparency and protecting continuity of care. Our momentum to accomplish all of these important changes has never been stronger.
Unger: Well, Dr. Scott, that is significant progress. What needs to happen next?
Dr. Scott: The time for legislation is now, and we need every physician to join our fight to fix prior authorization, and we need to fix it now. An updated version of the Improving Seniors Timely Access to Care Act was recently reintroduced on a federal level. This bill further streamlines and standardizes the prior authorization process within Medicare Advantage plan. It will codify many of the elements of the recent CMS regulation and will empower CMS to take additional steps to prevent care delays and improve transparency.
This bill has bipartisan support. It came close to passing last Congress. The AMA is going to focus on continuing to build support for this bill, and physicians can help by contacting their representatives about it. We're also going to continue to support legislation at the state level and make the case for change anywhere we can. Over the last few years, we've seen a big shift in policymakers' opinion on prior authorization. They see the need for change, and it's time to make that change a reality.
Unger: Well, Dr. Scott, thank you so much for joining us and, as always, for being such a strong advocate for physicians on this issue. Everything you've talked about today really speaks to the need for both patients and physicians to solve this problem. That's why fixing prior authorization is a top priority for the AMA. And I encourage you to support the AMA's efforts by becoming an AMA member at ama-assn.org/join.
That wraps up today's episode, and 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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