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.
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.