Physicians know they spend an inordinate amount of time dealing with the hassles of prior authorization, but when patients are being harmed because of it, it’s clear something has to change.
In this episode, AMA President Jack Resneck Jr., MD, digs further into the current state of prior authorization and how the AMA is working to fix it. Heather McComas, PharmD, director, Administrative Simplification Initiatives, AMA, and Emily Carroll, JD, senior legislative attorney, Advocacy Resource Center, AMA, join Dr. Resneck to talk about the latest reform efforts and how you can get involved. You’ll also hear about results of the AMA’s latest prior authorization survey conducted at the end of 2022.
- Jack Resneck Jr., MD, president, American Medical Association
- Heather McComas, PharmD, director, administrative simplification initiatives, AMA
- Emily Carroll, senior attorney, AMA Advocacy Resource Center
- Todd Unger, chief experience officer, American Medical Association
Unger: Welcome to Moving Medicine, a podcast by the American Medical Association. In 2022, 94 percent of physicians surveyed by the AMA said prior authorization delayed necessary care. Even worse, 33 percent reported these delays had caused a serious adverse event for a patient in their care. Physicians know prior authorization takes too much time and patients are being harmed because of it. Something has to change.
In today’s episode, we’ll hear from AMA President Dr. Jack Resneck Jr. and guests Heather McComas, AMA director of Administrative Simplification Initiatives, and Emily Carroll, senior legislative attorney with the AMA Advocacy Resource Center. They’ll talk about the state of prior authorization and how the AMA is working to fix it. Here’s Dr. Resneck.
Dr. Resneck: Welcome and thank you all for joining. I'm Jack Resneck, president of the American Medical Association. And it is a pleasure to be your host as we dive into an issue that's a major source of frustration for so many of us, prior authorization. If you've ever heard me speak pretty much anywhere, you know that bloated prior auth is a particular pet peeve of mine.
We're going to examine where prior auth reform efforts are right now, both at the state and federal levels. And we're going to hear from our own AMA experts about the ongoing work at the association and others to rightsize this very onerous process.
And when I travel and meet with physicians around the country, no matter what state I'm in and no matter what specialty they're from, each really has their own prior auth horror stories. In my specialty of dermatology, I knew insurers had really hit a new low when getting approval even for cheap generic cortisone creams that have been widely prescribed since the 1960s began to require several days of faxes and phone calls and appeals before patients could actually pick up their medication and start treatment.
At the same time, more and more of my patients with chronic conditions who had really found successful therapies began to face repeated prior auth hurdles when their health plan just changed formularies or sometimes, frankly, for no reason at all, which repeatedly disrupts their care.
When health insurance plans first came up with this process many years ago, we all remember it was primarily for brand new really expensive medications that had just come to market or brand new tests or new procedures. But it seems each year brings new prior auth demands that lead to care delays, and far too often, force patients to abandon treatments altogether. We actually see that somewhere between a quarter and a third of patients who go to the pharmacy and find out their medication requires prior auth and then we as physicians fight the good fight and get it approved. Almost a third of the time, patients don't even show back up to the pharmacy to pick up those medications and start treatment.
So what physicians are experiencing today and what patients are finding when they try to fill prescriptions at their pharmacy is that prior auth is being used for an incredibly broad variety of medications. It's a challenge for physicians, our office staff, and of course, our patients themselves. The fact is the prior authorization process as it currently exists is a burdensome, administrative nightmare.
We physicians often don't know at the point of care when we're sitting down in our electronic health records what's going to be on formulary, what's not, what's going to require prior auth, what's going to require step therapy? So our patients first learn that their medication isn't covered typically when they get to the pharmacy and the pharmacist tells them. And so begins that long saga of rejections, ridiculous alternative suggestions from the health plan, appeals sent by fax and ultimately, quote unquote "peer-to-peer calls" with someone at the health plan who's clearly not a peer.
And that's why the AMA has long made reforming the prior authorization process a focal point of our efforts to remove obstacles that interfere with patient care. It's why we generated a grassroots advocacy site, fixpriorauth.org, where thousands upon thousands of physicians and patients so far have already shared their prior authorization experiences to raise awareness to the public, to policymakers and to legislators about how it jeopardizes patient health.
I personally use many of those stories when I'm on the hill and in state legislatures. And it's also why we made fixing prior auth one of the five core pillars of our Recovery Plan for America's Physicians that we introduced last June.
The good news is that after years of advocacy on this issue, we're starting to see progress and momentum. It has helped that almost every policy maker I speak with has themselves had a prior auth experience or a family member or a close friend, and they know just how troubling this is.
Recently, there's been a particular emphasis in legislation we're seeing on reducing the growing volume of prior auth, as well as protecting some of the most impacted patients, those with chronic conditions and long-term diseases. For example, last year Texas passed a so-called gold card law which provides a pathway for many doctors to bypass the prior authorization process altogether, like TSA pre-check for prior auth.
This year, several states are attempting to do the same and we've seen some states move to prevent repeated prior authorizations as well for patients with chronic conditions so that they don't have to unnecessarily return to their physician's office or have their clinical stability threatened as they wait to get approval for the same treatment for the same condition that they know is already working.
There's lots more to do, and the AMA is continuing to push to reduce the overall volume of prior authorizations to increase transparency on the requirements, to promote automation and to ensure timely care for our patients. Thanks again for joining us and for being engaged on this important issue.
I want to introduce our panelists. So our first panelist is Heather McComas, director of Administrative Simplification Initiatives here at the AMA and one of our foremost experts on prior auth reforms. Welcome, Heather.
McComas: Thanks so much. Great to be here.
Dr. Resneck: And our second guest is Emily Carroll. Emily is the senior attorney in the Advocacy Resource Center, our state advocacy group at the AMA, and works on prior auth issues at the state level. Emily, welcome.
Carroll: Thanks for having me.
Dr. Resneck: Thanks to you both for being here. I have had the pleasure of working with both Heather and Emily for a number of years in various roles at the AMA, and they are real gems that we are lucky to have on our side. So Heather, I'm going to start with you if that's all right. The AMA released the results of its latest survey on the impact of prior auth. This has been something we've been doing annually for several years so that we can follow trends. Can you tell us about some of the findings related specifically to patient care?
McComas: Yeah, sure thing. And as you mentioned, we've been doing this survey annually for the past seven years, and we don't turn the data, but I got to say the results are reliably distressing. This year again, the overwhelming majority of physicians, 94%, reported that prior authorization is associated with care delays.
And these care delays aren't just inconveniences, they are annoyances. Our physicians are saying that prior authorization care delays actually hurt patients. 80% of physicians reported that prior authorization can lead to patients completely abandoning a prescribed or ordered course of care. 89% of physicians indicated that prior authorization leads to negative clinical outcomes.
And I think most alarming, one third of physicians reported that prior authorization has led to a serious adverse event for a patient in their care. And a serious adverse event is something like hospitalization, permanent impairment or even death. So these are really alarming statistics. And I think the numbers are very helpful to us in our advocacy on this issue.
But I also think, Dr. Resneck, as you were saying, that the numbers in combination with the patient stories are what really make an impact on this issue. So I was wondering if you can maybe put a human face behind some of these statistics. Can you give us a couple of examples of how prior authorization has hurt your patient's care?
Dr. Resneck: The thing that I've noticed the most really has just been the shocking volume increase as well. We have, at this point in my group, several staff who basically work exclusively on dealing with prior auth. And it so burns them out that we now actually have to rotate that around the office or else we have people quit because they just can't handle the boring nature of this unnecessary work.
And my daily experience with this is that most of the ones that we're filling out, they're not for big expensive new drugs. It's mostly actually for generics, for just things that I prescribe on a daily basis. Oftentimes things where there's not even a less expensive alternative. I don't know what the heck the health plan actually expects me to do instead. And sometimes it's even just Kafkaesque.
I had a patient―I told this story in a hearing a few months ago―who had severe head-to-toe eczema, hadn't slept for months and months. This was an adult. Out of work, really not very present with their family and I ended up putting them on one of the new targeted biologics. And I don't use these for every patient willy nilly. They are expensive. But for this patient, I got it approved. It was life changing, they were back at work, they were a productive citizen, their life was transformed really. And they'd been on the drug for about six months and then the health plan decided to re-prior auth one of their refills. So they just show up for a refill and get rejected at the pharmacy.
So I dutifully printed out the prior auth form for that health plan, handwrote extensive notes on how much this had changed their life and how well it was working, and faxed it, which is also a ridiculous part of this process, and it came back rejected. And I was kind of horrified, and was trying to figure out the reason for the patient. And the reason it was rejected was that the patient no longer met the severity criteria. Not enough of their body was covered, they weren't missing enough sleep, they weren't itching enough. I was like, wait a minute. That means the drug is working.
And it took over 20 phone calls to the health plan to fight this. And I was told things like, oh, just take the patient off the medication for several weeks. Let them have a bad flare and then they'll continue again, which is, again, just completely ridiculous. And on, I think, the 22nd or 23rd call, I finally won somebody over and got it overturned, but this is a lot of time that I could have spent with other patients. So it's really gotten ridiculous and out of hand. And this is, I think, what in every specialty my colleagues on the ground are facing―whether it's procedures or drugs―on a daily basis.
Heather, I want to come back to you. We often hear from health plans that they're using PAs to save on premiums and reduce unnecessary care. They sort of frame it as a bargain. What are some of the overall big picture costs of prior auth in terms of practice burdens, in terms of impact on overall medical and societal cost?
McComas: Yeah, sure thing. So obviously, we have the patient harms that you so eloquently talked about. It was a horrifying patient story. But putting that aside for a minute, just the overall societal costs of this process are just ridiculous. In our survey, practices reported completing four or five prior authorizations per physician per week. And that prior authorization workload for a single physician consumed almost two business days of physician and staff time. That is an enormous amount of administrative waste in our health care system. And Dr. Resneck, as you're talking about—because of this, a lot of practices in our survey, 35% reported having staff who just do prior authorization.
I guess we can certainly all feel in our hearts for those folks who do this all day every day. It's really frustrating and a horrible job that requires an unending amount of patience. But certainly, this is consuming a lot of practice resources, but it also is harming other areas of our economy. We included some questions in our survey asking about physicians’ perspective of this process on patients' ability to work.
And of physicians who have patients in the workforce, over half, 58% indicated that prior authorization has impacted patient job performance, whether it's the fact that the patient had to miss work because they had to schedule an extra visit to the physician because they had an unmet prior authorization need, or they were too ill to come to work because they couldn't get the care they needed or maybe they came to work, but they weren't productive because they didn't feel well or they were on the phone with their health insurer.
So I think it's really important to think about this aspect of the issue. I know in our advocacy, we are definitely trying to ramp up our messaging to the employer audience. We know that health plans present prior authorization to their employer clients as a way to save money. But I think with these stats it's clear that really puts that into question. At the end of the day if your employees are not well enough to come into work and do their job, it's really a big question mark that this process is actually saving employers money at the end of the day.
And then we added a question in this year’s survey asking physicians’ perception of the impact of prior authorization on overall health care resource utilization. And an overwhelming majority of physicians, 86%, indicated that prior authorization can actually increase the overall use of health care resources, which is, again, the polar opposite of what this process is supposed to be doing, right?
Health plans say they're doing it to save money. Physicians are saying in their experience, prior authorization is actually increasing overall health care costs because patients are being forced to try an ineffective treatment first through things such as step therapy. They're having to come in for extra visits or they're ending up in the emergency room and urgent care centers because they weren't able to get the care they needed in a timely fashion. So this really raises, I think, some overall existential questions about what we're doing with this process because we know it's hurting patients and it really is increasing costs all over our economy.
Dr. Resneck: Thanks, Heather. One of the questions I saw pop up is whether there's data other than our surveys of physicians that validate our findings. And I just want to say, the answer is a resounding yes. So one of the things that really helped us I think to accelerate the work at CMS was that GAO did a study looking at Medicare Advantage plans.
And not just the volume of prior auth, but they actually talked about the very high percentage of inappropriate prior auth denials that ultimately were overturned. And we've seen this repeated over and over again in the data. The health plans are very tight about limiting transparency of what they're doing on prior auth, but there have been some very clever studies done, including looking at an area before and after, for example, when a Medicaid plan adds prior auth requirements for mental health drugs. And showing that not only is it a pain for everybody, but that hospitalizations and actual patient outcomes change and get worse. So there are a fair number of data points out there that validate some of the data that we're seeing in our surveys.
Emily, I want to turn to you. Can you tell us a little bit about what AMA is doing in partnership with state medical associations and especially societies at the state level?
Carroll: Absolutely. Thanks, Dr. Resneck. So inactivity on prior authorization reform grows I think every year. And every time I talk to a state medical association, prior authorization is at the top of their advocacy agenda. I think this year alone, we saw or I'm tracking at least 30 dates with prior authorization reform bills and some of those states have multiple bills. So dozens and dozens of bills this year just kind of showing the momentum behind the need for this reform.
So first and foremost, we work with our colleagues at the state medical associations and the specialty societies working in the states to create more resources and push for prior authorization reform with them. Our Council on Legislation has created a model prior authorization reform bill that serves as a basis for a lot of the state activity going on and certainly a lot of our advocacy for what we'd like to see in state legislation.
We also create a number of issue briefs, draft testimony, data like the survey Heather's team does every year, which is so valuable to pushing for these reforms and then information on what’s happening in other states because good ideas should probably spread.
We frequently engage publicly in the states as well if that's helpful to the medical associations through letters, testifying on this issue, joint statements, really just any way we can support the physician advocates in the states on the ground.
We also really work to highlight this issue among national policy making organizations like the National Governors Association, the National Association of Insurance Commissioners, the National Council of Insurance Legislators, those sorts of groups. I think the more we engage those groups on prior authorization, the more prior authorization conversations that are happening at those meetings and among those organizations, and the more we can work prior authorization priorities into their model bills and model resources. I think that's more momentum on this issue that those individual policymakers can then take back to their states.
And finally, I'll say, if any state I think that has passed prior authorization reform legislation will agree with, multi-stakeholder coalitions are key. States have done amazing jobs in assembling these prior authorization coalitions of patients and hospitals, pharmacists. And we work really closely with some of those same groups at the national level building coalitions, determining our shared priorities, activating networks when needed, et cetera.
Dr. Resneck: What are states—just in terms of trends you're seeing, can you say a bit more about what states are focusing on?
Carroll: Yeah. And you talked a little bit about this, Dr. Resneck. I think we're seeing a change in the landscape of prior authorization reform conversations in the states. For many years, it was about streamlining and automating this process and making it easy to do, which is still certainly a priority and should certainly still be part of reform efforts.
But I think we've seen a shift recently, as you stated, focusing on volume reduction and really reducing those patient harms. So you brought up gold carding, which gained sort of national fame when Texas passed a gold carding bill a couple of years ago. And this idea is that—I love your analogy of a TSA pre-check―essentially if you have high approval rate with a plan for a service, you get a pass on prior authorization, so really reducing the volume of prior authorization for physician practices that regularly get services approved.
So the Texas law was designed to do that per service per health insurer. And since that law has passed, we've seen a number of other gold carding efforts in states. This year, I think we had—there are at least 12 gold carding bills right now pending. Michigan and Louisiana have both passed gold carding bills recently. Those are more general gold carding directives to health plans. And we also have gold carding requirements in West Virginia and Vermont, and hopefully, a number of more states by the end of the year.
We've also seen an uptick in legislation focusing on protections for patients with chronic conditions, as you also mentioned. We've seen a lot of bills this year and last that would reduce that repeat prior authorization for patients with chronic conditions, which would have benefited the patient you mentioned, Dr. Resneck, who was stable on a drug but had to go back for another prior authorization and ultimately got that denied initially. So really making sure that there's not that disruption in patient care when patients are stable on treatment.
We're also seeing a number of bills related to providing patients a grace period as they transition from one plan to another. So preventing a disruption in care that could happen when a new plan requires a prior authorization before a patient is allowed to access a drug or a service on their new plan. Maybe 60 days, 90 days are the trends we're seeing.
I think that's going to be really important as we anticipate a number of patients in the coming months transitioning off of Medicaid and into commercial plans and protecting their access to care there.
And then finally, I'll say we're seeing a growing interest in prior authorization data reporting. So data on denials, approvals, appeal rates, time to decision making, et cetera. A couple of states have enacted legislation over the last couple of years and I've seen a number of bills this year that would require that information to be reported to insurance commissioners who then would have to report it to the legislature in the public. A number of other states require that information to be reported on their plan websites or in other venues.
I think these are really important requirements as it gives us an insight into the black box of prior authorization. And then they also can allow us in the future to make more targeted reform efforts as we know where the pain points really are. So all these provisions and more are part of our prior authorization model bill and our principles and our policies. So we're excited to see them gaining traction in the state legislatures.
And I should say that we continue to see significant pushback on all these reforms from health plans arguing that they'll increase costs, and that prior authorization is important to managing care for patients. Dr. Resneck, I know you have done your fair share of talking to policymakers on this issue. In your experience, how do you refute those claims from insurers that prior authorization is needed to check physician prescribing or activity and have you been able to use your own personal experiences to address those false claims?
Dr. Resneck: It's an interesting question. Yeah, one of the things that I have noticed is that the tactics of the health plans have become pretty darn predictable when we're arguing in Congress or a state legislature about this. So inevitably, they will talk about how much money they have saved with this process. They don't then immediately mention their billions of dollars in profits or the salaries of their CEOs, but they talk about saved money.
And then they quickly turn to usually an anecdote about some surgeon out there somewhere in the country who's been doing tons of unnecessary surgeries and that they have protected patients with prior auth from this unnecessary or low-quality care. So I still share anecdotes of patients who've been harmed, but I think to go beyond their anecdote versus our anecdote, one of the things that has been useful is to come armed with data.
And that comes in a couple of different versions. So some of it is very aggregate data. So having our very helpful PA survey data and the trends over the years. But again, having a validation from outsiders like the GAO report in hand is very useful. So I can't overstate the value of that.
And then some of it is personal. And so now in addition to individual stories of patients of mine, I will typically walk into one of these hearings or one of these meetings literally with, in hand, the last 10 consecutive prior auth that I did, just a notation of what they are. And in some cases, depending on the time of day of the meeting or the hearing, I will have been on my electronic health record portal on my laptop in D.C. or wherever I've traveled to and will have been doing prior auths from my hotel room that morning.
Not making this up, we’ll just, if I do nine that morning, I'll write down what the nine were for and I'll say, look, I did nine prior auths this morning. Four of them were for refills where a patient was stable with a chronic condition, three of them were for generics, one was for a non-generic medication, but it was one where clearly the PBM is getting kickbacks for one version versus another and I'm having to change, and one was for an expensive biologic.
So here's my lived experience and it doesn't reflect at all what you're describing you're using prior auth for. And so just validating that with those personal data can also be useful. And a lot of times, if I know which insurance company is going to be—if it's a hearing at a state level and I somebody from company x, y, or z is coming, I'll just print out their formulary for my specialty―so that I have it and I just highlight the completely ridiculous things that are nonformulary or that require prior auth. And I'll just ask them to defend like, “Why is triamcinolone cream, invented in the 1960s, on your prior auth? This is ridiculous. This is indefensible and it's chewing up tons of our time and harming patient care,” and put them on the spot. So I think those are a couple of useful things—printing out a formulary, highlighting some things on there that are ridiculous, writing down your last 10 consecutive prior auth that you actually did.
We're using medication examples, the exact same thing happens with procedures, right? The examples of surgeries where you don't know when you start the surgery exactly what you're going to find. You try to prior auth three possible things, you only get one of them approved. You're in somebody's belly and you find something else. For all of our specialties, we have our examples of the just completely ridiculous things that we face that make no sense. So I find that really useful.
Thank you for being here. We’ve got a lot of work yet to do. Thank you so much, be well, have a great rest of your week. Take care.
Unger: Don’t miss part two of this conversation. Subscribe to the Moving Medicine podcast anywhere you listen to your podcasts or visit ama-assn.org/podcasts. Thanks for listening.
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.