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Why do prior authorizations take so long? Is prior authorization required for emergency services? Why would insurance deny a medication?
Melissa Garretson, MD, a pediatric emergency physician at Cook Children’s Health Care System and a member of the AMA Board of Trustees, discusses how to talk to patients about prior authorization, why prior auth takes so long, and how the AMA is fighting to fix prior authorization policy. AMA Chief Experience Officer Todd Unger hosts.
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- AMA prior authorization survey (PDF)
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- 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
- Melissa Garretson, MD, pediatric emergency physician, Cook Children’s Health Care System; member, AMA Board of Trustees
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about the impact of prior authorization on pediatrics. Joining us today in our studio is Dr. Melissa Garretson, a member of the AMA Board of Trustees and pediatric emergency physician at Cook Children's Health Care System in Fort Worth, Texas. I'm Todd Unger, AMA's chief experience officer. Dr. Garretson, what a pleasure to have you in our studio today.
Dr. Garretson: Thanks so much, Todd. It really is a pleasure to be here, especially talking about an issue that is such a critical pain point for all physicians.
Unger: Absolutely. And you're in somewhat of a unique position, being in both pediatrics and emergency medicine. Sometimes I think emergency medicine and prior authorization—that might be an oxymoron. So I'm curious. Talk to us a little bit about your weekly experience with prior authorization.
Dr. Garretson: Yeah, you're right. It is kind of an oxymoronic thing. You wouldn't think emergency physicians would have to deal with prior authorization. But prior authorization is one of those issues that cuts across all specialties, all modes of practice, and most importantly, tremendously impacts negatively patient care in our country. As an emergency physician, one of the things I see quite often is a failure of the prior authorization process and families bringing their children into the emergency department, begging us to provide the care that their kids need in a timely manner.
And when you look at that from that, that's a failure all the way around. The cost of emergency care is much higher than planned, deliberate care when you have the ability to wait for that to happen. But the fact that delays take six weeks, three months, six months as you fight through the prior authorization process is totally unacceptable, which is why the AMA is fighting so hard to rightsize prior auth.
Unger: So in a way, the patient side of that to try to get the care they need and kind of work around prior auth, they're going into the emergency department?
Dr. Garretson: That's exactly what they're doing. They are absolutely trying to work around a system that was designed to set up to deny care. Let's all be honest. Insurance companies make money when they don't pay for care. And so as a family who struggles trying to get their child the care that they need, those parents are desperate. They're going to take any avenue they can to try and move the system forward to get their kids the care that their physician and the family know they need.
Unger: That's a pretty unique challenge. Are there any other kind of challenges that you think are unique to the combination of medicine that you practice?
Dr. Garretson: There are. If you think about it—we have a joke in pediatrics—kids are not just little adults. And it is very, very true for so many reasons, right? Kids aren't just going to lay there for a painful procedure. Kids can't swallow medications that are in tablet form, a lot of times—even 14-year-olds. Some kids don't have the ability—for whatever reason—to swallow pills. There's a lot more flexibility that's required, taking care of pediatric patients. And insurance companies have a one size fits all, and that doesn't work, especially in terms of prior authorization.
Unger: Do you have any stories that illustrate that particular challenge?
Dr. Garretson: Sadly, I have a ton of—
Unger: I'll bet.
Dr. Garretson: —stories that illustrate that particular challenge. One of the ones that you and I have talked about before is medication formulation. Insurance companies have formularies for the medicines that they'll cover, largely driven by PBMs. And really, what happens is, they forget about the kid component of care. And lately, we're seeing a tremendous increase in the number of E. coli infections for urinary tract infections that are resistant to multiple forms of antibiotics, requiring very specific antibiotics—culture-proven, very specific antibiotics.
Insurance companies are paying for tablet forms of nitrofurantoin, which is a medication that's been around longer than I've been in medicine—starting in 1989—and should be very cheap. The liquid form is over $300. And kids need the liquid form. I had an eight-month-old just two weeks ago who had one of these types of urinary tract infections who needed nitrofurantoin. An eight-month-old doesn't meet any weight combination for a pill form. And the liquid form was something the family couldn't pay for.
So what are my options? I can't get it prior approved. It's an emergency department. I work 24/7. There's nobody there to talk to. Well, that's wrong, isn't it? The second thing that happens is, I can't try and formulate it myself. You need a special solution to get the medicine to actually dissolve. What do I do then? Do I admit the patient to the hospital, rather than being able to take care of this in outpatient setting?
That's just one. We get a tremendous number of kids with seizure disorders who come in—and status epilepticus, which is seizures that won't stop—because they're going through the prior authorization product again with a medication they've been on for years that kept them stable and out of the emergency department.
But because a new insurance company is mandating they get prior approval for a medication like that, they fall off their medication, and they end up in my emergency department—and oftentimes intubated and in the ICU, while we stabilize their seizure disorder. This is a tremendous problem that dramatically impacts kids.
Unger: Absolutely, impacting patients and also impacting physicians. We see prior authorization—along with a number of other burdens—as having major contributions toward physician burnout. It's a widespread problem, obviously. But coming in at number four, pediatrics for physician burnout—do you see—and I think the answer is yes—that prior auth is a major part of what's driving that?
Dr. Garretson: It really is. And when you look at private practice—especially with the medication shortages we're facing—for the past couple of years, medicine for attention deficit disorder—we've had shortages right and left of different formulations of different medications. Well, insurers only cover one type, right? One is OK without a prior auth procedure, and then everything else requires prior authorization.
Imagine, as a pediatrician with a child who's doing well in school on their particular ADHD medicine—and now you can't find it. And then you can't get the new one prior approved because it's not the one that's covered—even though there's a nationwide shortage. It makes no sense to me. And as a pediatrician, my goal is to help kids stay healthy—and when I can't, to help optimize their outcomes so they can go to school and interact with their peers in an appropriate way and grow up and become adults. That's the goal of a pediatrician.
And when you make it impossible for me to do that, that truly is a moral insult to, in my soul, what I want to do as a physician. And that really is what we're talking about when we're asking people to help support our fight to rightsize prior authorization and fix it now.
Unger: Well, let's go to that topic. Obviously, the AMA has made fixing prior authorization one of its key priorities. Tell us a little bit more about why it's so important that organizations like the AMA are taking a leading role in addressing this problem.
Dr. Garretson: Well, I think physicians—we get very siloed in our work. My nose is the next patient that I see, the 50 people, sadly, in my waiting room, waiting to get in to see me. And that's where my energy and my time is. And prior authorization—like, I have a new rescue medication for breakthrough seizures. It's administered nasally. The old one is administered rectally.
Now, imagine you're a kid at school with a breakthrough seizure, and the nurse is going to pull down your pants in front of all of your peers to administer the rectal medication. You going to want to go to school? Not me, right? That's horrifically embarrassing and traumatizing to that child. The new nasal medication—there's probably about seven different formulations of the exact same medication, all with different names. Do you know that insurers only cover one? And they don't tell you which one. You have to guess.
So every time I write a prescription for that, it's not one prescription. It's four different attempts to get the right one and the right formulation for that insurance that'll pay for that child to be able to go to school and not worry about a breakthrough seizure. They have a rescue medicine that goes through their nose. You want to talk about frustrating and burnout? I can't get that child the right care, even though it's the exact same medication. It just has different names. That's ridiculous.
And none of us signed up to be physicians who couldn't provide the care that we know our patients need at the right time and the right place. And that is incredibly frustrating. Pediatricians are pretty happy, "excited to care for patients" kind of people. That's what we like to do.
So the fact that pediatricians are number four on the list of burnout will tell you how grave the insult is that every day—41 times a week on average—you are calling into question my experience, my training and my judgment about what's right for the patient—the one that I've laid hands on, you haven't. No wonder we all need to get involved in this and fight this problem. And no wonder our AMA has championed this issue as one of the ways we can restore joy in medicine.
Unger: Absolutely. And just listening to the scenario that you've—
Dr. Garretson: It's awful.
Unger: —painted there about treating somebody in a classroom like that, and then the figure that you talked about—41 times a week, the undermining power of that prior authorization—it's no wonder physicians out there are feeling pretty frustrated and feel like this has just been this long battle.
Dr. Garretson: That's right.
Unger: What do you say to them to kind of encourage them?
Dr. Garretson: Well, I think we've made progress. The fact that everybody—everybody—is talking about the barriers to care that prior authorization is is the first step. The AMA's made tremendous strides and has a bill in Congress—H.R. 4968—about rightsizing prior authorization for our seniors.
We've made tremendous strides last year, in terms of having CMS reinterpret a regulation to assure that insurers make prior authorization a much speedier process—not quite to where the AMA wants it, but close. We're close—to also saying you need to get rid of prior authorization for those physicians who are good at getting prior auth through 90% of the time is the first step. Gold Cards are a great thing.
And 14 states are currently considering legislation in their legislatures now. So if you're in one of those 14 states, contact your state legislators to tell them how important this is to allow you as a physician in that state to take care of your patients and keep physicians engaged and practicing medicine. That's what we need to do. But there's tremendous, tremendous building blocks for us.
And I think the next step really needs to be physicians with our patients—sharing with our patients the struggles we go through, getting them the care they need. We try really hard to make that be a wall that our patients don't see. I don't want them to feel my stress. I want them to be good.
And so if I reach out to them and say, hey, I am going through this process, which is part of my job—that's fair—but I need you to understand how hard this is right now so you can communicate both with, perhaps, the people that have provided your insurance—or even our legislators—to give them the real-time pain that you're facing as a patient or a parent of a patient in getting the care that you need.
Unger: I think that's a great way to close. There's a lot of progress. We need everybody's support out there, and especially these stories—both from physicians and from their patients—so that we can continue to make progress on this. Dr. Garretson, I think we'll end on that positive note. I just want to say thank you for joining us. Fixing prior authorization is a top priority for the AMA. And we encourage you to support our 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. 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 video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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