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What is the new health care law in Illinois? Is Illinois getting rid of prior authorization? What is the Illinois Healthcare Protection Act?
Recent policy changes in health care: Richard Anderson, MD, FACS, president-elect of the Illinois State Medical Society, discusses what the new Illinois health insurance laws mean for doctors and patients. AMA Chief Experience Officer Todd Unger hosts.
- The AMA is your powerful ally, focused on addressing the issues important to you, so you can focus on what matters most—patients. We will meet this challenge together. Join us.
- Learn how the AMA is fighting prior authorization.
- 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.
- Learn more about our AMA advocacy priorities, including:
- Reforming Medicare payment
- Fighting scope creep
- Fixing prior authorization
- Reducing physician burnout
- Making technology work for physicians
Speaker
- Richard Anderson, MD, president-elect, Illinois State Medical Society
Transcript
Unger: Hello, and welcome to the AMA Update Video and Podcast. Today we're talking about a new law in Illinois that's removing more big prior authorization burdens. We'll discuss the details of that law and how the Illinois State Medical Society helped to advocate for it.
Our guest today is Dr. Richard Anderson, president-elect of the Illinois State Medical Society in Peoria, Illinois. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Anderson, welcome.
Dr. Anderson: Thank you very much, Todd. I'm glad to be here today.
Unger: Well, prior authorization is on everybody's minds these days. So much burden associated with it. And this law is a significant win for patients and physicians. Why don't we start with just a quick overview of the prior authorization reforms that are in this new law and when they take effect.
Dr. Anderson: Sure. So Illinois has been very fortunate to be able to have the opportunity to work on prior authorization, and in some cases even eliminate prior authorization. We passed a bill in this last general assembly that further defines some prior authorization issues. But really, our story started in 2019, when we began working on prior authorization. We were able to put together a group of health care advocacy and patients to be able to work on summarizing or decreasing the burden that was on prior authorization.
And so in 2021, legislation was actually passed on prior authorization in Illinois. That became law in January of 2022, and it had several major key points in it. The highlights that I wanted to make sure that we talked about or mentioned were reducing the time for health care insurances to give prior authorization. Depending upon whether something is urgent or emergent, there had been a fixed frame and no patient will go longer than a week without having to have their prior authorization approved.
Another big issue was reviewer qualifications for denials. Now, insurance carriers have to provide for their peer reviewer, must be a specialty related peer reviewer in order to deny a claim. Third, duration of approvals. Depending on whether something was acute or chronic, there is a defined definition of how long prior authorization is actually good for.
And the fourth one is transparency. Prior authorization requirements that individual insurance carriers must provide guidelines on their website, or wherever they publish things, as to what is required for prior authorization, and that they follow clinically relevant guidelines.
This year we made a change, and we followed along with the governor who proposed a health care reform act. And in his act, a couple additional things that were added to this was the ability to get rid of stepwise therapy, and also the ability to get rid of prior authorization for people who get admitted for medical health issues.
Unger: You just talked about almost all of the key issues around burden with prior authorization, everything from how long it takes to get one, the peer review issue, transparency around that, duration of the authorization itself.
These are huge achievements, and they're going to have a big impact when they go into effect. What's that going to look like for patients and physicians in practice?
Dr. Anderson: Anytime you can take a burden and decrease that burden, you then allow more time. And so what this is going to do, by taking away some of that burden in prior authorization, it gives physicians more time to spend with their patients. And what it's also going to do, it's also going to help speed up our process of making our patients healthier sooner by decreasing that time.
I had a little story that happened during this event when we were working on this. I had a patient that needed an urgent procedure done. And the day before their surgery was scheduled, my office got a call and said the insurance company is denying the procedure. And she was just like, whoa, wait a minute. What are you talking about?
And it took a fair amount of time. In fact, I had to rearrange the operating room schedule the next day so I could get the authorization done so that patient could get that urgent procedure done. That kind of stuff just needs to go away.
Unger: Absolutely. And much like the AMA, the Illinois State Medical Society has been advocating for prior authorization reform like this for years. And your work played a huge role in making the state law reality. How do you get something like that done?
Dr. Anderson: You start with your membership. We started, we pulled our membership. One of the big concerns that our membership had was the huge, burdensome process that was there on prior authorization. Once we got that settled, it kind of followed right along with the AMA survey that they did that said all physicians were being burdened by prior authorization.
We began to form a coalition of patient advocacy groups and patients. We started getting stories from patients, from providers. Putting those together, meeting with lawmakers, discussing this with lawmakers. And we found out lawmakers had some of the similar stories that we were having. They were having frustrations with prior authorization.
And so our coalition got started with a campaign called Your Care Can't Wait. Once we were able to get all this done, we were able to have several meetings with our legislatures. We were able to get some champions with some hard work from our legislatures and using some AMA language to craft a legislation. And by looking at some prior states that had done some legislations before us, as well, we were able to have craft some legislation that was able to become law. And this was a very powerful grassroots effort put on by doctors, patients and health advocacy groups.
Unger: Wow, what a powerful partnership that is. And a great display of how model language that gets developed, either at the federal level or in one state, can be exported so that everyone can make progress really quickly. What a terrific example. And just another example of the kind of momentum that's been building for prior authorization reform in different states. Do you think that other states will soon pass laws like the one that you just are getting passed?
Dr. Anderson: Boy, I sure hope so. We weren't the first state to do this. We modeled our legislation after some of the other states that had previously done it. I think this is exceptionally important that more people get involved and do this. And we are offering and helping several other medical associations work on this very issue at their level.
Unger: You mentioned earlier in our discussion this issue of, this is something that many policy makers actually have personal experience with. We found that in other discussions at the federal level especially, too. And those stories that you get from physicians in the state, from their patients in telling those stories really resonates. Beyond that, what do you feel like state societies can do to make this issue top of mind for policymakers?
Dr. Anderson: I think the real focus needs to be, is that prior authorization harms patients. There's delay in care, there's delay in treatments. And like you said, there are a lot of stories out there on people who have these—patients, lawmakers, physicians, we can all come up with stories spontaneously about these kinds of situations.
But I think the real important thing is, is we need to get rid of the bureaucracy of prior authorization. And need to make it a public health priority, and take the politics out of it.
Unger: Let's talk a little bit more about that. Because to make that a priority, it really is partnerships between organizations like yours at the state level, and of course, organizations like the AMA at the federal level. Why is that so important to make this issue a priority at the federal level as well?
Dr. Anderson: Well, state laws are limited that they can only regulate plans at a state level. Most people who are employed get their insurance through related entities that are regulated at a federal level. And so our ERISA laws become exceptionally important.
And so getting something into a federal level is what we really need to encompass more organizations and more people through the ERISA laws. The work that the AMA has been doing at the federal level is crucial. And we all need to support that. We support that. We need to continue to work on that. And we really appreciate that work that the AMA has been doing on this issue nationally.
Unger: You've gotten a lot accomplished with this new law. What else, in terms of change, would you like to see next in Illinois?
Dr. Anderson: Enforcement is a big issue. In Illinois, and it's the same thing as in other states that passed prior authorization, we need to be able to streamline and make sure regulators know how important it is that these processes be recognized and enforcement be done appropriately.
I think the other big issue that's out there, too, is working on other diseases—specifically chronic diseases. When a patient has a chronic disease and they've worked with their health care provider and they've come up with a good solution that works for them, we shouldn't be interfering with that. And so I think we need to get chronic conditions on the next book for prior authorizations.
Unger: Absolutely. Dr. Anderson, thank you so much for joining us, and for all of the work on advocacy that you and the Medical Society in Illinois have done. Fixing prior auth is a top priority for the AMA. And to support our efforts, 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. Be sure to subscribe for 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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