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Critical changes are needed to fix the time-wasting, care-delaying payor process. Highlighting prior authorization’s patient impact goes a long way.
As state legislatures consider bills that could advance the positive changes needed to fix prior authorization, sharing individual patients’ stories can have a huge impact on getting state lawmakers to better understand why such changes are so vital.
AMA President-elect Bobby Mukkamala, MD, has his own story to share about prior authorization battles. Diagnosed with a brain tumor last fall, he needs to secure prior authorization every 14 days for a medication that he takes to keep the cancer at bay. He has seen the power that patients’ firsthand accounts have on lawmakers.
Dr. Mukkamala, a Michigan otolaryngologist, brought a patient with him to testify before the Michigan Senate about the harsh impact that prior authorization has on real people. Dr. Mukkamala sought prior authorization for a positron emission tomography (PET) scan after his patient’s stage 1 tonsil cancer diagnosis so that they could determine the best treatment option. When the patient finally received the PET scan three weeks later, the cancer had progressed to stage 2.
“It was amazing how effective just the story of an individual patient was relative to national statistics in convincing the people at the Senate hearing that: Wow – yeah, this is a problem,” Dr. Mukkamala said during a recent AMA webinar examining how states are taking up key health care issues such as prior authorization legislation.
During the webinar, a panel of AMA experts discussed their work with national, state and specialty medical societies to address key legislative priorities, including prior authorization, scope of practice, and physician well-being.
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles. The AMA’s most recent survey of physicians shows how prior authorization is blocking lifesaving treatments.
Where States Are Focusing Efforts
Bills before state legislatures this year vary widely. Some are comprehensive, targeting numerous issues, while others are smaller bills focused on one aspect of prior authorization and are perhaps part of a multiyear plan to implement prior authorization reform, according to Emily Carroll, a senior legislative attorney at the AMA Advocacy Resource Center who took part in the webinar. There are some general themes among the bills, including a recognition that delays in prior authorization must be addressed. Carroll outlined three of these.
- Automating the prior authorization process. “There are new federal standards for both the drugs and medical services benefits, and we really support aligning state requirements around automation with those,” Carroll said.
- Reducing the volume of prior authorization, another change that the AMA supports. Some of the bills include exclusions for certain types of services, such as treatment for substance use disorder or cancer care or for generic medications. Other bills aim to reduce repeat prior authorizations, especially for patients with chronic, long-term conditions. Such protections could prevent the repeated prior authorizations that patients such as Dr. Mukkamala are required to obtain for ongoing treatment.
- Proposals to establish gold carding. This would create a path for physicians who have high approval rates from an insurer on a particular service or a particular group of services to be exempted from having to seek prior authorization for those services.
State legislatures also are considering or advancing measures that:
- Address the qualifications that a health plan’s reviewer must have to make prior authorization decisions. The AMA advocates that the reviewer should be a physician in the same specialty of the physician making the request, licensed in the same state and have treatment experience that allows them to make that medical necessity determination.
- Ensure more data collection. This includes requiring insurers or state insurance commissioners to post statistics about approvals, denials, wait times and other relevant data on their websites.
- Promote continuity of care. For example, if a patient switches plans, they would have 90 days to stay on their medication without going through another prior authorization.
- Boost transparency when a request is denied, during the appeals process, and for the criteria used to make determinations.
- Set parameters for how augmented intelligence (AI) is used. For example, if an AI tool recommends a denial, a physician ultimately needs to be the one making the denial and not AI. California enacted a bill to that effect last year.
How the AMA Is Helping
The AMA can be a resource for state medical associations, providing model legislation and tailoring assistance to what each state needs. For example, the AMA can offer a broad perspective on what other states have done, along with what is happening federally and nationally that states can build upon.
“We try and develop the resources so that they have turnkey solutions when they’re having these conversations,” Carroll said, noting that the AMA is advising state medical associations and legislators on how they can use 2024 federal rules on prior authorization to promote reform in their states.
The AMA can also engage directly on the legislation if a state association finds that helpful, and can write letters of support for legislation, testify, submit testimony or review bills, among other things.
Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
