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Administrative Burden: Legislative and Regulatory Advocacy to Improve Physician Wellness - Carroll
This document discusses problems with prior authorization requirements, including delayed patient treatment and excessive administrative burdens on physicians and staff. It summarizes the results of an AMA survey that found high prior authorization burdens for physicians and delays in patient care. The document outlines principles for reforming prior authorization developed by a multi-stakeholder workgroup. It discusses state legislative efforts regarding prior authorization and step therapy reform and provides an overview of the AMA's model prior authorization legislation.
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Administrative Burden: Legislative and Regulatory Advocacy to Improve Physician Wellness - Carroll
- 1. Addressing the burdenof prior authorization American Academy of Family Physicians State Legislative Conference November 3, 2017 Emily Carroll Advocacy Resource Center American Medical Association
- 2. © 2017 AmericanMedical Association. All rights reserved. Problems • Utilization Management Programs: Cost-containment protocols requiring physicians to receive advanced approval before a health insurer will cover a particular drug or medical procedure • Concerns: • Delayed patient treatment • Questioning practitioner’s medical judgment • Manual, time-consuming process requires resources that could be spent on clinical care 2
- 3. © 2017 AmericanMedical Association. All rights reserved. AMA Survey Overview • 1000 practicing physician respondents • 40% PCPs/60% specialists • Web-based survey • 24 questions • Fielded in December 2016 3
- 4. © 2017 AmericanMedical Association. All rights reserved.4 Weekly Average Number of PAs & Processing Hours Combined Number of PAs in Past Week 23% 23% 23% 17% 14% 0% 20% 40% 60% 80% 100% Prescription + Medical Services 0-5 PAs 6-10 PAs 11-20 PAs 21-40 PAs Over 40 PAs Mean: 16.4 Median: 8.0 Range: 0-200 22% 19% 23% 23% 13% 0% 20% 40% 60% 80% 100% Physician + Staff Combined 0-2 hrs 3-5 hrs 6-10 hrs 11-20 hrs Over 20 hrs Combined Number of Hours Spent Processing PAs in Past Week The average of 37 weekly prior authorizations per physician takes the equivalent of approximately two business days of physician/staff time to process (16 hours). Mean: 36.6 Median: 20.0 Range: 0-750
- 5. © 2017 AmericanMedical Association. All rights reserved.5 Survey Takeaways: Practice Burdens • 75% of surveyed physicians described prior authorization burdens as high or extremely high • Over 1/3 of surveyed physicians reported having staff who work exclusively on prior authorization Source: Physicians Practice, August 25, 2015; http://www.physicianspractice.com/physician-productivity/prior- authorization-agony
- 6. © 2017 AmericanMedical Association. All rights reserved.6 Survey Takeaways: Patient Impact • Nearly 60% of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions— and over 25% of physicians said they wait 3 business days or longer • 90% of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care
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- 8. © 2017 AmericanMedical Association. All rights reserved. Prior Authorization Reform Workgroup 8 • American Medical Association • American Academy of Child and Adolescent Psychiatry • American Academy of Dermatology • American Academy of Family Physicians • American College of Cardiology • American College of Rheumatology • American Hospital Association • American Pharmacists Association • American Society of Clinical Oncology • Arthritis Foundation • Colorado Medical Society • Medical Group Management Association • Medical Society of the State of New York • Minnesota Medical Association • North Carolina Medical Society • Ohio State Medical Association • Washington State Medical Association Over 100 additional organizations have signed on as supporters of the Workgroup efforts following the January release
- 9. © 2017 AmericanMedical Association. All rights reserved. Principles Overview • 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 9
- 10. © 2017 AmericanMedical Association. All rights reserved. Outreach Targets for Principles • Utilization management entities • Health plans • Benefit managers • Health plan accrediting bodies • URAC • NCQA • Standards organizations • Policymakers 10
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- 12. © 2017 AmericanMedical Association. All rights reserved. AMA model prior authorization legislation 12 • Require payers and vendors to offer ePA • Payers must display current PA requirements, including clinical criteria, on websites and make information available to all stakeholders; • Payers must provide physicians 60 days notice before implementing new PA requirements or amending current requirements; • Statistical information regarding PA approvals and denials must be displayed on payers website; • Payers must respond to PA requests in two business days for non-urgent services; one business day for urgent services and sixty minutes for post evaluation or post-stabilization services following emergency care (no PA for emergency care); • Payers must provide coverage for emergency services necessary to screen and stabilize the patient, regardless of the network status of the provider; and • Stop payers from revoking or restricting a PA for a period of 45 working days from the date the health care provider received the PA.
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- 14. © 2017 AmericanMedical Association. All rights reserved. State of the states – prior authorization laws 14 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
- 15. © 2017 AmericanMedical Association. All rights reserved. Recent activity on prior authorization: comprehensive reforms Delaware Ohio Arkansas Washington Virginia 15
- 16. © 2017 AmericanMedical Association. All rights reserved. Step-therapy: model legislation • Broad coalition of providers, consumers and other stakeholders pushing step-therapy legislation • Balanced approach: focused on easily accessible, streamlined exceptions process for: • patients who are stable on their current medication, • patients who have tried and failed the indicated medication before, or • patients for whom the medication would be contraindicated. 16
- 17. © 2017 AmericanMedical Association. All rights reserved. Step-therapy activity 17 Texas Kentucky West Virginia Indiana Iowa Missouri New York Louisiana California Washington Vermont Connecticut Maryland Illinois Mississippi
- 18. © 2017 AmericanMedical Association. All rights reserved. What can you do? 18 Push principles out to local plans, benefit managers and other stakeholders Build coalitions Collect stories Work with state medical associations on legislation Sign onto the principles
- 19. © 2017 AmericanMedical Association. All rights reserved. Follow-up information Prior authorization and utilization management reform principles: https://www.ama-assn.org/practice-management/addressing-prior-authorization- issues Contact : Emily Carroll, JD Senior Legislative Attorney, AMA emily.carroll@ama-assn.org 19