Prior Authorization

How DC prior authorization reform improved patient care by changing pre-authorization requirements

. 8 MIN READ

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What is the prior authorization legislation in DC? Is prior authorization good or bad? How does prior authorization work? How can I speed up my prior authorization?

Our guest is Susanne Bathgate, MD, past president of the Medical Society of the District of Columbia and associate professor of obstetrics and gynecology at George Washington University. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Susanne Bathgate, MD, past president, Medical Society of the District of Columbia; associate professor, obstetrics and gynecology, George Washington University 

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Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about another big prior authorization reform win for physicians and patients, this time in Washington, D.C. Joining me is Dr. Suzanne Bathgate, past president of the Medical Society of the District of Columbia, who helped to advocate for this reform. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Bathgate, I'm looking forward to hearing about all your achievements today.

Dr. Bathgate: It's great to be here. Thank you for having me.

Unger: Eager to find out more because shortly before the new year, the DC Council passed the Prior Authorization Reform Amendment Act to bring long overdue changes to prior authorization in DC. It's a major accomplishment for your medical society MSDC as well as a victory for physicians and patients. Let's start by talking about some of the key reforms that are in this act.

Dr. Bathgate: The DC legislation requires that prior authorization be valid for at least one year and for patients with chronic conditions as long as necessary to avoid disruptions in care. The legislation requires that the plan reviewer be a licensed physician in the same specialty, including for pediatric specialties, and requires a peer-to-peer review opportunity before a denial. A response is required in 24 hours for urgent care. This legislation prohibits prior authorization on medication-assisted care for opioid use disorder. And this in particular is so important considering the impact of opioid use disorder on our society. Now detailed prior authorization data and statistics are required to be posted by plans as well.

Unger: There are a lot of big wins right there. These reforms are now officially in effect. It's only been a short period of time but I'm curious how was the experience so far for physicians and patients? Are you seeing changes?

Dr. Bathgate: So because of the congressional review period, this legislation has only gone into effect in the past few weeks. We anticipate that we will hear that patients will receive their care and medications in a more timely fashion and that staff will be freed up from telephone hold and paperwork to provide other care that is patient facing and enhances access.

Unger: Now obviously, this is a big move in Washington, D.C. But this issue of prior authorization is vexing across many, many states. In fact, dozens of states are now working to pass their own prior authorization reforms this year. When you think about your most effective advocacy tactics, what advice would you give or share with those medical societies and advocates out there so that they can achieve the same thing you did?

Dr. Bathgate: Well, it took MSDC many years to pass this legislation. And we had many setbacks. I would say be prepared for the long haul and be persistent. Critical to our success I think was engagement of the physician community. We had testimony from a number of physicians from different specialties from psychiatry and internal medicine, OB/GYN and myself like maternal fetal medicine. These physicians told their stories to make the situation real for lawmakers. Prior authorization impacts so many important aspects of health care, including timely topics like behavioral health and reproductive health, and can significantly affect our ability to provide equitable health care.

As myself as a practicing maternal fetal medicine specialist, I testified about my experiences struggling to obtain progesterone to reduce preterm birth risk. In certain patients at high risk for preterm birth, using supplemental progesterone can decrease that risk. For instance, at 20 weeks gestation, an ultrasound is performed to assess fetal anatomy and the length of the maternal cervix. If the cervix is short, there is a higher risk of preterm birth. But the use of vaginal progesterone mitigates this risk. I have experienced delays in obtaining authorization for this medication. Starting progesterone is time sensitive and delays can potentially reduce the effectiveness of this intervention with possible lifelong consequences for the child born prematurely.

Unger: Again, another great example of the potential harm of delays due to prior authorization. Throughout your campaign, you had the full support of the AMA. Obviously, a big area of focus for us, too. Our AMA president at the time even testified to the DC council in support of this bill. Can you talk to us about other ways that you got support from the AMA to work at the state level?

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Dr. Bathgate: Yes. AMA support was really important. The Prior Authorization Reform Amendment Act in DC was based on an AMA model bill. AMA provided data and other resources, helped with bill analysis and wrote letters of support. And AMA joined MSDC coalition efforts and worked closely with other advocates in and outside of medicine to gather support and did webinars on this issue with council staff. I think the involvement and support of the AMA was essential to the passage of this legislation in the District of Columbia.

Unger: Well, we were very proud to stand with MSDC throughout the legislative process. You were president during much of that period. Tell us a little bit about your personal experience with prior authorization that help keep you motivated.

Dr. Bathgate: Well, as a maternal fetal medicine specialist, offering screening for recessively inherited genetic conditions is considered standard of care as recommended by the American College of Obstetrics and Gynecology, ACOG. Ultimately, the goal of genetic screening is to provide individuals with meaningful information that they can use to guide pregnancy planning based on their personal values. If a patient has been appropriate counseled on the limitations and expectations of carrier screening, the barrier of the need for prior authorization should not impede their access to these screens.

Similarly, it is standard of care to offer screening for abnormal chromosome makeup of the fetus such as Down Syndrome, Trisomy 18 and Trisomy 13. Cell-free DNA and maternal blood can predict these conditions with a great deal of accuracy. ACOG recommends making this blood test available to all pregnant people. Some insurance companies cover this screening for all without prior authorization, some require prior authorization, some for pregnant people under 35 or with specific conditions. In both these cases, failure to obtain this information in a timely fashion because of delays of insurance approval may limit the diagnostic testing options and pregnancy management decisions for these families.

Unger: Well, all your work has really helped to build momentum for reform. And as you pointed out earlier in your discussion, it's those stories and your personal experiences when they get transmitted to legislators, either at the federal or the state level, just have really moved the needle. So big win on the at the district level here. Also progress on the national front. As many of you may know, the AMA scored a significant win at the national level that will save practices an estimated $15 billion over the next 10 years. The movement to fix prior authorization is stronger than ever. Dr. Bathgate, what change would you like to see happen next?

Dr. Bathgate: Well, the legislation in effect in DC is currently for the private market only and needs to be funded for Medicaid. This is the next challenge. We believe in health equity so we want to make sure that prior authorizations reform apply to all plans. Nationally, we'd like to see DC's and AMA's reforms in place for all plans. Hopefully, Congress can look across the street and see DC as a model for reform of prior authorization.

Unger: Absolutely. Dr. Bathgate, thanks so much for joining us today and congratulations to you and the Medical Society of DC for this big win. If you found this discussion valuable and the other efforts that we've been talking about on prior auth, you can support more programming like it by becoming an AMA member at ama-assn.org/join.

That wraps up today's episode. We'll be back soon with another AMA Update. You can find all our episodes, video, podcasts, you name it, 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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