April 4, 2019
Issue SpotlightPhysicians score a win in bid to fix prior authorization
Kentucky patients—particularly those with chronic conditions on an established medication regimen—should have speedier access to treatment as a result of a new law reforming health insurance company prior authorization (PA) processes. And their physicians next year are expected to have a major administrative burden reduction.
Gov. Matt Bevin signed the measure—Senate Bill 54—into law March 26 after it was approved by the Kentucky House of Representatives and Senate by votes of 97–1 and 37–0.
"The AMA was honored to support the Kentucky Medical Association (KMA) in their push for a better and more streamlined prior authorization process, and we congratulate KMA and all Kentuckians who will benefit from the important changes that SB 54 will bring," said AMA Board of Trustees Chair Jack Resneck Jr., MD.
"State legislation is a critical component of the AMA's multipronged prior authorization campaign, especially as it is clear most health insurers simply aren't going to make changes to the prior authorization process on their own," Dr. Resneck added. Kentucky certainly can serve as an example for other states who want to protect patients from harmful and unnecessary delays in care."
The AMA offers prior authorization resources to support reform, improve practice efficiency and provide data to highlight the need for change. To learn more and share your story, visit AMA's FixPriorAuth.org website or search social media by using the #FixPriorAuth hashtag.
The Kentucky bill was championed by state Sen. Ralph Alvarado, MD. An AMA and KMA member, Dr. Alvarado chairs the Kentucky Senate Health and Welfare Committee and is very familiar with prior authorization. He succinctly spelled out the problems with the process when addressing the Kentucky House Banking and Insurance Committee at a Feb. 27 hearing.
"They're touted as cost-containment mechanisms, but—in reality—they often will increase costs to patients, providers and even the insurers themselves," Dr. Alvarado said in his testimony. "With increasing regularity, health plans and MCOs [managed care organizations] require unnecessary prior authorizations, which delay patient care, disrupt the patient-provider relationship and decision-making process."
Insurers also "demand a manual, time-consuming process that expends resources that could be spent on clinical care, and escalates overhead costs for practices including hospital and pharmacies, many of which are already financially stressed," Dr. Alvarado said.
The new law takes effect Jan. 1, 2020. Under the measure:
- Physicians will receive responses on PA requests within 24 hours for urgent services and within five days for nonurgent services
- Prescriptions for chronic-condition maintenance drugs will be valid for one year, and any change in dosage during this period will be covered
- Insurers' PA procedures will be posted online as well as a complete list of services requiring PA
- Insurer PA reviewers will be licensed physicians and, when possible, of the same specialty as the requesting physician
- Physicians and other clinicians will be able to electronically request and transmit PAs
"These will be dramatic changes," said KMA President Bruce Scott, MD (pictured left). "We are going to remain vigilant that the law is implemented as intended and health plans comply."
Patients should immediately notice speedier access to treatment and the one-year authorization for maintenance drugs, he said. Physician practices will notice that requests get processed sooner, without long times waiting on hold or sending and resending faxes.
The law, largely based on AMA model legislation, mandates that health plans adopt electronic PA processes. It specifically mentions that "facsimile, proprietary payer portals and electronic forms shall not be considered electronic transmission."
"My staff is going to love it," said Dr. Scott, a Louisville, Kentucky, otolaryngologist and facial plastic surgeon who is president of Kentuckiana Ear Nose & Throat in Louisville, Kentucky. He is also vice speaker of the AMA House of Delegates.
Despite the law's overwhelming support in the legislature, passage was not without difficulty as the insurance lobby pushed back when reforms were introduced last year.
Dr. Scott credits passage to the work of Cory Meadows, KMA's deputy executive vice president and advocacy director, who presented legislators with the right mix of patient stories and relevant statistics.
The AMA's prior authorization survey was an important component of the KMA advocacy effort. He said lawmakers took notice that 75 percent of the 1,000 physicians surveyed reported that PA led patients to abandon treatment and 28 percent said it has led to an adverse event such death, hospitalization, disability or even death.
When health plans at a hearing pushed to lengthen the period for nonurgent PAs to seven days, Dr. Scott said the mother of a young woman with epilepsy told legislators that waiting seven days for a prescription could cause her daughter to have seizures.
"That was the end of the health plan argument," Dr. Scott said.
For more than a decade, the AMA has advocated for expanded coverage and key health insurance reforms that help patients. That work continues as the AMA fights to protect gains made by the Affordable Care Act (ACA)—now being challenged in federal court—while supporting House lawmakers in their recent efforts to strengthen the ACA.
Signed into law nine years ago, the ACA ushered in gains that most now consider essential — creating options for affordable, high-quality individual coverage for millions while also guaranteeing coverage for pre-existing conditions and other important protections for the most vulnerable. The task now is to build on what has been shown to work and continue to make enhancements where needed. In releasing a set of bills to improve the ACA last week, lawmakers demonstrated an understanding that access and affordability are still challenges for many individuals and families.
The ACA improvement bills H.R. 1385, H.R. 1386, H.R. 1425, H.R. 987, H.R. 986, H.R. 1010 would reauthorize the state reinsurance program, restore funding for the ACA navigator and enrollment consumer education programs, authorize $200 million for states to establish state-based health exchanges, and limit use of Section 1332 waivers and ACA waivers to undermine the ACA's pre-existing condition consumer protections.
The AMA supported these bills with recommendations on further enhancing the bills to increase health care access, lower premium and out of pocket costs and protect consumers. The bills were reported favorably. They were considered by the full committee this week.
In addition, the AMA and other leading physician organizations filed an amicus brief this week in the case of Texas v. United States to defend the significant coverage gains and key patient protection provisions of the ACA. "The district court ruling that the individual mandate is unconstitutional and inseverable from the remainder of the ACA would wreak havoc on the entire health care system, destabilize health insurance coverage and roll back federal health policy to 2009," said AMA President Barbara L. McAneny, MD. "The ACA has dramatically boosted insurance coverage, and key provisions of the law enjoy widespread public support. The district court's decision to invalidate the entire ACA should be reversed."
In a recent comment letter on the draft report of the federal Interagency Pain Management Best Practices Task Force, the AMA commended the Task Force for its authoritative, evidence-based report and urged implementation of its recommendations. The AMA expressed appreciation for the report's clear recognition that policies and practices that only promote, prioritize or pay for minimizing prescription opioid prescribing risk undertreating pain and lead to sub-optimal outcomes, stigma and barriers to care.
The AMA strongly supports the recommendations for health insurance policies to be changed and aligned to support comprehensive multimodal, multidisciplinary, restorative pain care. The report also underscores the AMA's view that the voluntary guidance on opioid prescribing developed by the Centers for Disease Control and Prevention has been misapplied, leading to considerable pressure on physicians to reduce opioid prescribing, and often leading to patient suffering.
On March 27, the House Energy and Commerce Health Subcommittee marked up a number of bills, supported by the AMA, to lower prescription drug costs by approving generic drug competition. The generic drug competition bills, H.R. 938, H.R. 1499 and H.R. 965, would address practices used by manufacturers to block market entry by generic competitors, including pay-for-delay settlements, "parking" the 180-day exclusivity granted the first generic applicant to block follow-on applicants and refusing to provide the samples needed for generics applicants to get U.S. Food and Drug Administration (FDA) approval. H.R. 1503 and H.R. 1520 would modernize the Orange book for drug patents and authorize a Purple book for biologic patents to ensure generic manufactures have the information they need to apply to the FDA. H.R. 1781 would ensure the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission have access to data needed to evaluate the practices of various entities within the pharmaceutical supply chain state reinsurance program. These bills were considered by the full committee this week.
On April 2 the House Education and Labor's Subcommittee on Health, Employment, Labor and Pensions held a hearing entitled: "Examining Surprise Billing: Protecting Patients from Financial Pain." The hearing had an educational focus, with testimony from a panel of health care stakeholders, including Families USA, the Brookings Institute, the American Benefits Council and a professor, Jack Hoadley, PhD, research professor emeritus, Georgetown University, Health Policy, to discuss proposed solutions to surprise billing. Witnesses also explored lessons learned from state law approaches to addressing this phenomenon.
The panel agreed that patients should not be held responsible for the dispute in payment between providers and insurers over an out-of-network bill, generally expressing the opinion that surprise billing results from a market failure where normal insurance rules of a negotiated in network price in exchange for a stream of patients does not apply to certain specialties, because services of hospital-based physicians have inelastic demand. Witnesses urged the committee to pass federal legislation that would create a benchmark for a fair out-of-network payment; cautioned against having that rate set as a percentage of charges which would drive up premiums and overall costs for the health care system; and urged some percentage of Medicare payments, such as 125 percent, be adopted instead. They also supported a process whereby the provider and insurer are encouraged to negotiate to reach a fair payment or enter arbitration. Witnesses talked about the importance of applying these patient protections against surprise bills across insurance products, and beyond the emergency room, discussed how air ambulances and ground ambulances are also contributing to the problem of surprise bills with their out-of-network status. Lastly, they discussed the importance of a federal law applying these protections to Employee Retirement Income Security Act-regulated plans, as patients in these plans are not protected by state laws aimed at curbing surprise bills and they are equally impacted by this unfair billing practice.
The AMA submitted a statement for the record emphasizing the need to hold the patient harmless and instead to create a process where providers and insurers can reach a fair payment amount for out-of-network care in situations where a patient cannot choose the provider, while also pushing insurers to be required to have networks of physicians and other providers sufficiently available to care for their beneficiaries. Separately the AMA joined in a letter with the American Hospital Association and the Federation of American Hospitals to express joint opposition to one proposed solution which would call for the creation of payment bundles for episodes of emergency care that would be administered by the hospital. All three groups noted the complexity and inappropriateness of such a model for care that is as highly variable as the full spectrum of services provide to emergency patients.
The AMA has developed a new resource for physicians who participate in Medicare accountable care organizations (ACO) and those who are considering applying to the program. An AMA summary of the 2018 ACO final rule provides a high-level overview of key changes in the regulations governing Medicare ACOs. These changes include an expanded application of risk adjustment to all of an ACO's assigned patients instead of just new patients and a new distinction between "high revenue" and "low revenue" ACOs, which refers to the proportion of total spending on an ACO's patient population that is fee-for-service revenue to the practices, hospitals and other participants in the ACO. In addition, tables included in this new resource provide a side-by-side comparison of key features of the previous Medicare ACO tracks with the new ACO tracks established by the final rule.
The AMA recently responded to a request from Senator Mark Warner (D-VA) seeking comments and recommendations to address cybersecurity vulnerabilities in the health care system. Congress and the administration should do more to address cybersecurity vulnerabilities in health care because:
- Cybersecurity is a patient safety issue
- Cyber-attacks are inevitable and increasing
- Physicians are interested in receiving tools and resources to assist them in their cybersecurity efforts
- The health care sector exchanges health information electronically more than ever before, putting the entire health care ecosystem at risk
Based on an AMA/Accenture cybersecurity survey, 8 in 10 physician practices have experienced some form of cybersecurity attack. Physicians recognize that it is not "if," but "when" they will experience a cyber-attack. Small practices need extra help in navigating cybersecurity challenges. The federal government needs to empower physicians to actively manage their security posture, not hinder them. Specifically, physicians are interested in receiving tools and resources to increase their cyber hygiene. In its response, the AMA highlighted the increased urgency to advance policies that remedy vulnerabilities in cybersecurity.
The AMA's cybersecurity survey also shows that 85 percent of physicians believe it is "very" or "extremely" important to share data to provide efficient, quality care but are concerned about how to share it securely. This is increasingly important as the industry moves towards value-based care, telemedicine and remote patient monitoring. To that end, the AMA has developed physician resources to help bolster cyber hygiene in their practices. The Digital Health Implementation Playbook includes a Cybersecurity 101 Section discussing cybersecurity concerns when implementing digital health into a practice and provides a sample vendor-information request form including a section on data security privacy.
The AMA's response also highlighted the need for increased security awareness, technical capacity and federal efforts. A recent federal advisory report noted that improved cybersecurity awareness and education are needed to strengthen cybersecurity. Meeting this goal requires an educated workforce. The AMA's cybersecurity survey further identifies the need for education. The AMA recommends technology vendors and device manufactures explain patient safety issues related to cybersecurity in plain English, using standardized formats and with a consistent meaning of risk. The AMA specifically calls out the needs of small practices. Many physician offices do not have stand-alone information technology (IT) departments, requiring extra help in navigating cybersecurity challenges and dealing with legacy technologies. Only 20 percent of small practices have internal security officers, so they typically rely on health IT vendors for security support. The AMA urges technology vendors to be more transparent and proactive about disclosing costs to physicians upfront, updates and patch management, and the lifecycle of technology.
The AMA is also calling for policy changes to improve cybersecurity surrounding legacy technologies. Patient safety and cyber risk must be properly allocated across all involved parties. Incentives should be structured so those best positioned to have knowledge of risks and best positioned to minimize harm are incentivized to do so. The AMA recommended additional federal policies to urge manufacturers and EHR vendors to proactively minimize risk to patients and share accountability for protecting patient data and maintaining data integrity. The AMA is encouraging Congress and the administration to help reframe the conversation from punitive provider requirements to an opportunity for positive incentives. Potential incentives include creating a cybersecurity anti-kickback safe harbor and Stark (physician self-referral) exception, developing improvement activities for QPP that promote good cyber hygiene and permitting multiple paths to the Health Insurance Portability and Accountability Act (HIPAA) security rule.
The U.S. District Court of Maine ruled last week in support of a person's right to mediation-assisted treatment (MAT) while incarcerated in Smith v. Aroostook County. This is the latest important victory in recent months after Pesce v. Coppinger. The case was spearheaded by the ACLU of Maine and included support from the Maine Association of Psychiatric Physicians, Maine Medical Association and Northern New England Society Of Addiction Medicine.
In reaching her decision, Judge Nancy Torresen noted that "the withdrawal protocol is not a treatment for opioid use disorder and that "with the help of her medication, Ms. Smith has been in active recovery for her opioid use disorder for approximately ten years. During that time, Smith has regained custody of her four children, secured stable housing for her family and obtained employment."
Judge Torresen emphasized that "based on the evidence offered by the Plaintiff's experts, the available scientific evidence and Ms. Smith's medical history, I find that forcing Ms. Smith to withdraw from her buprenorphine would cause her to suffer painful physical consequences and would increase her risk of relapse, overdose and death."
AMA model legislation includes provisions that would require state departments of corrections and all other state entities responsible for the care of persons detained or incarcerated in jails or prisons to ensure all persons under their care be assessed for substance use disorders, and also require them to make MAT available without limitation or restriction on the type of medication or other treatment prescribed by the person's physician.
For more information, e-mail the AMA's Daniel Blaney-Koen.
Idaho's Governor Brad Little recently signed into law H.B. 182 – the most liberal expansion of pharmacist scope of practice in the country. The new law allows pharmacists to independently diagnose and prescribe drugs to patients for conditions that in the pharmacist's judgment:
- Do not require a new diagnosis
- Are minor and generally self-limiting
- Have a Clinical Laboratory Improvement Amendments-waived test used to guide diagnosis or clinical decision-making
- Threatens the health or safety of the patient if a prescription was not immediately dispensed
As enacted, the bill removes language that required the Board of Pharmacy (BOP) to authorize conditions for which pharmacists may prescribe. While far from perfect, this previous legislation, which was enacted in 2017 despite strong opposition from the AMA and Idaho Medical Association, limited pharmacist prescriptive authority to specific conditions authorized by the BOP and approved by the legislature. This regulatory process at least afforded the physician community the opportunity to comment on conditions prior to approval by the BOP and resulted in some important patient safety provisions.
H.B. 182 moved swiftly through the statehouse, passing the House and Senate unanimously. In a letter to Governor Little, AMA Executive Vice President and CEO James L. Madara, MD, expressed the AMA's strong opposition to the bill and deep concerns that this legislation "grants pharmacists wide latitude to prescribe medications to patients, young and old, regardless of the severity or complexity of the patient's condition and including such illnesses as cancer, bipolar disorder, glaucoma, hypertension and diabetes." Dr. Madara further emphasize that "the AMA is deeply concerned with how this legislation is drafted and the assumption that it will be applied conservatively. Make no mistake, this legislation allows pharmacists to provide medical care for which they are not trained, without access to patients' full medical records, in a setting that is not conducive to performing a full medical examination or protecting patients' privacy. This bill is illogical and impractical in its application and raises serious patient safety concerns."
The AMA and the Medical Society of New Jersey (MSNJ) applauded this week's announcement by New Jersey Governor Phil Murphy and state Human Services Commissioner Carole Johnson for helping end needless administrative barriers to evidence-based treatment for patients with an opioid use disorder. Effectively immediately, New Jersey Medicaid will no longer require prior authorization for MAT.
"The AMA strongly urges all states that have not taken this step to do so immediately," said Patrice A. Harris, MD, MA, president-elect of the AMA and chair of the AMA Opioid Task Force. "Removing prior authorization for MAT should be occurring in every state Medicaid agency—and in the commercial and self-insured markets. As we know from our patients, delayed treatment can have deadly consequences."
"The Medical Society of New Jersey fully supports the announcement and the increased access to treatment for our patients," said John Poole, MD, MSNJ president.
The Community Care Program proposed rule provides a framework for how the U.S. Department of Veterans Affairs (VA) intends to partner with non-VA physicians to ensure that veterans received timely access to quality health care. The AMA submitted comments on March 25 that were generally supportive of the proposed rule while acknowledging that many details, such as VA contracts with non-VA providers, community care authorizations and claim processing, will be addressed in subsequent rulemaking.
The Veterans Health Administration (VHA) will host a webinar on April 18 from 1 p.m. to 3 p.m. Eastern time summarizing the Community Care Program and the corresponding VA regulation. There will be an in-depth discussion on topics from referrals to claims to Community Care modernization and improvements. This is part of a series of VHA webinars that are held monthly.
The Centers for Medicare & Medicaid Services (CMS) recently released the 2017 Quality Payment Program (QPP) Experience Report and Appendix, which include details about clinicians' experiences during the first year of the Merit-based Incentive Payment System (MIPS) and alternative payment models (APM). Because of AMA's advocacy efforts that resulted in the "Pick Your Pace" transition year, 95 percent of clinicians participated and 93 percent received a positive incentive payment in the first year of MIPS.
The AMA is planning to share feedback with CMS about additional data points and specifics that would be helpful to understand clinicians' experiences in the QPP. The AMA is also interested in feedback from specialty societies and states.
Please send notes about the 2017 QPP Experience Report to Terri Marchiori, AMA Director of Federation Relations.
Here are three key insights from the 2017 QPP Experience Report:
- Program flexibility was vital to first-year participation. About one-quarter of eligible clinicians reported quality measure data for a period of 90 days to less than a year, while three-quarters reported full-year data. In addition, of the approximately 40 percent of clinicians who reported Advancing Care Information data, 60 percent took advantage of the option to report using the transition measure set that did not require a new certified electronic health record (EHR) product. The AMA continues to advocate for improvements to MIPS by making it more holistic and simple.
- Most clinicians participated as groups or an ACO. In 2017, 54 percent of clinicians participated as part of a group, 12 percent individually and 34 percent through an APM. The Medicare Shared Savings Program and Next Generation ACO Model had the highest rates of MIPS participation through an APM.
- Improvement Activities category reflects extensive patient-centered initiatives. Clinicians reported more than three million improvement activities in 2017. The top five improvement activities reported reflect practices' patient-centered initiatives, including providing 24/7 access to patient's medical records, patient engagement through portals and attestation as a Patient-Centered Medical Home. This MIPS category recognizes physician practices are on the forefront of increasing care coordination and integrating innovative care approaches.
The AMA's suite of tools and resources are available to help make sense of QPP requirements.
Through a creative collaboration with the AMA Alliance, the U.S. Drug Enforcement Administration (DEA) recently reached out to physicians and other DEA-registered clinicians to encourage them to become certified to prescribe buprenorphine to treat opioid use disorder (OUD) and to learn how to prevent drug diversion.
Filmed at a DEA-sponsored Practitioner Diversion Awareness Conference, DEA officials make clear in the video about OUD treatment that only a small percentage of the DEA registrants who are eligible to obtain certification to prescribe buprenorphine have done so, and they strongly encourage more physicians to pursue this certification. The DEA also stresses that the agency is not targeting physicians who provide OUD treatment with special enforcement actions. Instead, the agency wants to increase the number of physicians who are providing this treatment.
A second video produced with the AMA Alliance focuses on the partnership that is needed between the DEA, physicians, pharmacists and others to promote safe prescribing practices and prevent drug diversion. DEA officials interviewed in this video also emphasize the agency's view that the vast majority of physicians are prescribing legally and that its enforcement efforts focus on a tiny fraction of clinicians engaged in egregious illegal practices.
CMS through the Open Payments Program is required to publicly report annually on June 30 items of value that are given to physicians and teaching hospitals. Preceding the public data release, physicians are given 45 days, which typically begins in early April, to review their data and dispute errors. The 2019 review and dispute period is April 1 to May 15.
Physicians planning to review their 2017 Open Payments Data should test their CMS Enterprise Portal (EIDM) logon credentials beforehand. If physicians are having trouble registering, EIDM Quick reference guides or available for new users and existing users. Physicians can also email Medicare's Open Payment Help Desk or call (855) 326-8366.
Apr. 22-25: The Rx Drug Abuse & Heroin Summit is the largest and most-recognized conference committed to addressing the opioid crisis. Government officials, first responders, law enforcement personnel, clinicians, physicians, nurses, educators, public health and prevention officials, and families and people in recovery are represented. The conference agenda is designed with timely and relevant information to address what is working in prevention, treatment and law enforcement. AMA Trustee S. Bobby Mukkamala, MD, will be representing the AMA, giving a presentation April 24, "Moving slowly to treatment: policymaker, payer and physician leadership to end the epidemic."
The 2019 Summit returns to the Hyatt Regency in Atlanta.
Visit www.rx-summit.com to explore the agenda and register.
April 24: Learn how findings from a new RAND Corp./AMA study, "Effects of Health Care Payment Models on Physician Practice in the U.S." can help guide practices' efforts to successfully adapt to changes required by complex alternative payment models (APM) in a new webinar. Register now for the webinar at 1:00 p.m. Eastern time.
May 22: A long-time physician will share her practice's journey through the phases of transformation and how both the struggles and the triumphs have prepared the practice team for operating and succeeding in an APM. Register now for the webinar at 1:00 p.m. Eastern time.Back to Top