State Strategies for Administrative Simplification
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2018 State Legislative Conference October 25 - 27, 2018 Ft. Lauderdale, FL
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State Strategies for Administrative Simplification
- 1. Presented to the American Academy of Family Physicians 2018 State Legislative Conference Emily Carroll American Medical Association Advocacy Resource Center October 26, 2018 Health Insurer, M.D.? Efforts to advance prior authorization reforms
- 2. © 2018 American Medical Association. All rights reserved. Prior authorization It’s not in your head – it’s getting worse! 2 3% 11% 35% 51% 0% 20% 40% 60% 80% 100% Increased significantly Increased somewhat No change Decreased somewhat or significantly 86% of physicians report PA burdens have increased over the past five years
- 3. © 2018 American Medical Association. All rights reserved. The burden is real • Volume • 29.1 average total prior authorizations per physician per week • Time • Average of 14.6 hours (approximately two business days) spent each week by the physician/staff to complete this prior authorization workload • Practice resources • 34% of physicians have staff who work exclusively on prior authorization • Repetition • 79% of physicians are sometimes, often or always required to repeat prior authorizations for prescriptions when a patient is stabilized on a treatment for a chronic condition
- 4. © 2018 American Medical Association. All rights reserved. Patients are being harmed 4 9% 7% 23% 18% 16% 12% 10% 6% Don't know More than 5 business days 3-5 business days 2 business days 1 business day More than a few hours but less… A few hours Under 1 hour Average response times 30% of physicians report waiting at least three business days for responses 1% 1% 6% 38% 39% 15% Always Often Sometimes Rarely Never Don't Know Delays in Care 92% of physicians report care delays as a result of prior authorization Treatment abandonment 78% of physicians report prior authorization can at least sometimes lead to treatment abandonment 3% 2% 19% 57% 19% 2% Always Often Sometimes Rarely Never Don't know
- 5. © 2018 American Medical Association. All rights reserved.5 92% of physicians report that prior authorization can have a negative effect on clinical outcomes This arguing lasted about 3 days - 3 more days of delaying carefully timed treatment that is helping him to stay in a sort-of remission state. – Nancy C. Everything my pain management doctor had tried to get for me through a prior authorization has been denied. Now I’m just in constant pain. – Sherri H. My son had to go days without medications because they needed 'prior authorization' even though the neurologist started him on them while he was admitted due to having 100+ seizures a day. – Ariana S. I've been denied a treatment that worked for 11 years. – Gina F. Do I hold my breath while waiting 3 days to breathe with inhalers? It's like a game of chess. – Joyce W. I have had to make multiple calls and wait as long as 2 weeks trying to obtain authorization for an MRI when there were abnormal mammogram or pelvic sonogram findings. – Dr. Nina S. I … struggle getting medications approved for ADHD, acne, and even some critically important psychiatric medications, leaving patients with severe depression and hallucinations untreated with delays ranging from days to weeks – Dr. Heather V.
- 6. © 2018 American Medical Association. All rights reserved. Prior Authorization and Utilization Management Reform Principles • Underlying assumption: utilization management will continue to be used for the foreseeable future • Sound, common-sense concepts • 21 principles grouped in 5 broad categories: • Clinical validity • Continuity of care • Transparency and fairness • Timely access and administrative efficiency • Alternatives and exemptions
- 7. © 2018 American Medical Association. All rights reserved. Consensus Statement on Improving the Prior Authorization Process • Released in January 2018 by the AMA, AHA, AHIP, APhA, BCBSA, and MGMA • Five “buckets” addressed: • Selective requirements to reduce volume of providers subject to PA • Regular review of services/ drugs requiring authorization • Improved transparency and communication • Protections for continuity of care • Automation to improve efficiency and transparency
- 8. © 2018 American Medical Association. All rights reserved. State legislation • Require payers and vendors to offer electronic prior authorization (ePA) • Payers display current prior authorization requirements and clinical criteria, on websites and make information available to stakeholders • Payers must provide notice before implementing new requirements or amending current requirements • Statistical information regarding prior authorization approvals and denials be posted • Required response time for urgent and non-urgent services • Restrictions on retrospective denials • Establishing length of authorizations • Step therapy exceptions processes
- 9. © 2018 American Medical Association. All rights reserved. 2018 Legislative Activity (prior authorization and step therapy) 9 AK MD WA OR NV ID AZ NM UT CO WY MT ND SD NE KS OK FL LA AR MO IA MN WI IL OH KY TN MS AL GA SC NC VA WV MI PA ME NY HI NH RI NJ MA DE DCCA TX IN VT CT
- 10. © 2018 American Medical Association. All rights reserved. Advancing the conversation: What are changes patients and physicians can feel? • Requiring reductions • Gold carding Reducing the volume • Basis for all requirements • Clinical decision support tools Evidence-based clinical criteria • Practice of medicine • Same specialty/licensed in state Qualifications of reviewer
- 11. © 2018 American Medical Association. All rights reserved. Thinking about opportunities where prior authorization reforms are possible and needed: • Regulation of pharmacy benefit managers • Health insurance transparency efforts • Movement toward value-based purchasing • Access to treatment for opioid use disorder • Enforcement of mental health parity • CMS activity/interest • Others?
- 12. © 2018 American Medical Association. All rights reserved.12 Coalitions, coalitions, coalitions!
- 13. © 2018 American Medical Association. All rights reserved. Tools and resources: What do you need? • fixpriorauth.org • Principles and consensus statement • Model legislation • Patient stories • Social media tools • Op-eds • Educations materials
- 14. © 2018 American Medical Association. All rights reserved. Thank you! Emily Carroll Senior Legislative Attorney American Medical Association emily.carroll@ama-assn.org 312.464.4967
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Editor's Notes
- Based on 2017 AMA survey: 1000 practicing physician respondents 40% PCPs/60% specialists Web-based survey 27 questions Fielded in December 2017