In early August, the American Medical Association (AMA) held its annual state advocacy strategy meeting in Chicago. This meeting pulls together all state medical societies and national specialty organizations. Over three days, participants engage in roundtable discussions on issues, solutions and best practices for health policy. Networking opportunities abound.
The meetings showcase legislation that has been both positive and negative for practicing physicians. Two major successes were highlighted this year: the passage of AMA-inspired model legislation for prior authorization reform in Ohio and Delaware.
ACR Participation
The ACR is an active participant in an ongoing workgroup whose objective is to amend the AMA-inspired prior authorization language so that it reflects the changing environment of the rheumatology practice. The workgroup comprises representatives of more than 20 state medical societies and national specialty organizations, bringing to the table a comprehensive view of all the administrative challenges providers are facing in the evolving healthcare system.
AMA data suggest that prior authorization is becoming an increasing problem for physicians, with hard costs estimated at:
- One physician hour per week;1
- More than 13 (13.1) nursing hours per week;1
- More than 6.3 clerical hours per week;1
- $2,161–3,430 per full-time equivalency of a physician, meaning the time and revenue lost to a practice when a physician makes prior authorization request;2 and
- Interactions with insurers—$82,975 annually per physician in overhead expenses compared with Canadian physicians who spend $22,205 annually.3
The Current AMA Model for Prior Authorization
According to AMA surveys, physicians seek to control three major areas in the prior authorization process:
- Transparency in health plan criteria;
- An appropriate clinical basis for prior authorization criteria; and
- Fluctuations in health plan coverage.
All over the country, physicians are finding that insurers’ prior authorization criteria are opaque and inaccurate when it comes to their formularies. When recommending treatments, physicians can’t predict what procedures require prior authorization. Moreover, even if they do try to predict what treatment(s) may or may not require prior authorization, providers are finding that insurers’ websites are inaccurate. These practices have encouraged provider organizations to partner with patient advocate organizations. Patient advocates can speak to the human cost of the utilization review process. This is something insurers continue to have a difficult time justifying in legislative committees.
Providers continue having success speaking directly to the clinical appropriateness of the prior authorization process. Brought before legislative committees, providers easily and effectively explain how certain treatments have changed patient lives. In a 2010 AMA survey of 2,400 physicians, two-thirds of physicians reported waiting several days to receive prior authorization for drugs, and 10% waited more than a week—this is time that could otherwise have been passed with physicians delivering life-changing treatments to their patients. These delays in care can lead to further damage to the patient’s health and increased costs to the system—something the prior authorization process is purported to prevent.
Another increasing practice by insurers is changing existing health plans mid-year in a contract. All over the country, physicians are seeing stable patients require prior authorization for medications they have already been receiving. Health plans justify this action because businesses that provide health insurance for their employees are constantly seeking to reduce costs, hence the mid-year plan changes. Employees are having more of their insurance costs shifted to them and away from their employers.
Electronic Prior Authorization
State legislatures are realizing the problems created by an overly burdensome utilization review process and adopting electronic prior authorization (ePA). According to Point of Care Partners, 15 states require health plans to support some type of ePA submission, which includes web-based portals. These laws require a standard form that is updated and reviewed by stakeholder groups and maintained by the state’s commissioner of insurance. Some include deadlines by which the insurer must respond to appeals in addition to why the claim was denied. Laws passed in both Ohio and Delaware include these requirements. Ohio requires all health plans to respond to a prior authorization in 48 hours for urgent care services and 10 calendar days for any request. Delaware requires a two-business-day response for drug requests, 48 hours for urgent requests, three days for health services if electronically submitted and five days for health services that are not electronically submitted.
An additional win with the Ohio law: Any change to an insurance plan must be preceded by a 30-day notice to the provider. This helps eliminate the guessing game physicians have to play when deciding on a course of treatment. Knowing the policies ahead of time further empowers physicians to deliver care to their patients without delays.
Mandating support for ePA is significant because multiple studies have shown that ePA is a much more economical and efficient means of submitting information. Although ePA reform does not eliminate all the problems associated with utilization review, it does begin to reduce the amount of resources physicians must expend on behalf of their patients.
What You Can Do
Physicians must continuously support advocacy efforts by their state and specialty societies. In all states that have reformed their prior authorization laws, the state medical society has taken the lead. These policies affect every specialty in medicine. Being involved with your state society ensures the unique problems your rheumatology practice faces are addressed when drafting these laws.
Additionally, the more rheumatologists who are members of the AMA, the more the College can push rheumatology issues to the forefront across the country. We request that all ACR members either renew their membership or join the AMA to continue to allow the ACR to leverage its advocacy activities utilizing the AMA’s ability to convene groups to address our common needs, as well as its significant advocacy activities.
“It is important to have as many avenues to advocate as possible,” says ACR Government Affairs Committee Chair Will Harvey, MD, MSc, “and the AMA is a good one. More importantly, I think many of us have felt that the AMA has been more and more responsive to issues of concern to us. This year, we are in danger of losing an AMA slot because not enough of our members are also AMA members. I strongly urge you to renew [your membership in] or join the AMA this year. Things are going to get worse before they get better, and we need to keep pushing AMA policy in the right direction. Regardless of how you’ve felt about [the AMA] in the past, now is the time to get off the fence and join.”
We need your help now to keep rheumatology’s seat at the table. You can help by renewing your membership in or joining the AMA. We also need ACR members to specify the ACR as your specialty organization by “voting” for the ACR, which confirms for the AMA that you want to be counted toward rheumatology’s seat at the table.
In addition, make sure you are a member of your state medical society and work to bring the rheumatologist’s perspective of the PA reform process to your state as well.
Ryan Larosa is senior manager of state affairs at the ACR.
References
- Casalino L, Nicholson S, Gans D, et al. What does it cost physician practices to interact with health insurance plans? Health Affairs. 2009 July–Aug;28(4):533–543.
- Morley C, Badolato D, Hickner J, et al. The impact of prior authorization requirements on primary care physicians’ offices: Report of two parallel network studies. J Am Board Fam Med. 2013 Jan–Feb;26(1):93–95.
- Morra D, Nicholson S, Levinson W, et al. US physician practices versus Canadians: Spending nearly four times as much money interacting with payers. Health Aff (Millwood). 2011 Aug;30(8):1443–1450.
