The country’s largest physician organization is taking steps to rein in bureaucratic prior authorization requirements that can lead to delayed and disruptive treatment for patients.
At a meeting this week, the American Medical Association’s (AMA's) delegates adopted new policies specifically targeting peer-to-peer (P2P) review of prior authorization decisions and the particular burden of prior authorization during a public health emergency.
"P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated," said AMA President Susan Bailey, M.D., in a statement.
"Particularly during a public health emergency like COVID-19, unnecessary prior authorizations should not stand between a patient and care they need," Bailey said.
The new AMA policies adopted call for P2P prior authorizations to be made actionable within 24 hours of the discussion; the reviewers to follow evidence-based guidelines consistent with national medical society guidelines where available and applicable; and the temporary suspension of all prior authorization requirements and the extension of existing approvals during a declared public health emergency.
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a consensus statement (PDF) outlining a shared commitment to improving five key areas associated with the prior authorization process. However, health plans have made little progress in the last three years toward implementing improvements in each of the five areas outlined in the consensus statement, according to the AMA.
Also during the meeting, the AMA announced Jack Resneck Jr., M.D., a dermatologist from the San Francisco Bay Area, as the new president-elect. Following a yearlong term as president-elect, Resneck will assume the office of AMA president in June 2022.
Here are other policies the AMA delegate adopted during the meeting:
Telehealth regulation and physician licensure: To continue the use of telehealth after the COVID-19 public health emergency—not as a replacement for in-person care but as part of a hybrid model in which physicians utilize both in-person and telehealth visits to support optimal care—delegates adopted policy calling on the AMA to “continue supporting state efforts to expand physician-licensure recognition across state lines in accordance with the standards and safeguards outlined” existing AMA policy on telemedicine coverage and payment.
Addressing the digital divide: The AMA delegates approved a policy intended to help close the digital divide in access to telehealth services. The new policy will help ensure that minority communities, individuals residing in underserved rural and urban areas, older adults and individuals with disabilities can reap the benefits and promise of telehealth, the AMA said.
The new policy calls for expanding physician practice eligibility for programs that assist in the purchase of services and equipment to provide telehealth services. In partnership with diverse patient populations, hospitals, health systems and health plans need to launch interventions aimed at improving telehealth access, including leading outreach campaigns. To spread the benefits of telehealth, the AMA will support efforts to design telehealth solutions to accommodate those with difficulty accessing technology—including seniors, vision-impaired patients and individuals with disabilities.
Bolster rural healthcare: Delegates adopted new policies to address the health needs of the rural population, protect and enhance their access to healthcare and ensure payment to rural hospitals is adequate and appropriate. The new policy calls for public and private payers to create a capacity payment to support the minimum fixed costs of essential services, including surge capacity, regardless of volume.
The physician organization also calls for payers to provide adequate service-based payments to cover the costs of services delivered in small communities and use only relevant quality measures for rural hospitals and set minimum volume thresholds for measures to ensure statistical reliability. The policy calls for the creation of voluntary monthly payments for primary care that would give physicians the flexibility to deliver services in the most effective manner with an expectation that some services will be provided via telehealth or telephone.
"Most of the hospitals at risk of closing are small rural hospitals, serving isolated communities. Without long-term solutions, the health needs of rural populations will not be met. The AMA has long advocated for telehealth as a critical part of effective, efficient, and equitable health care delivery, and ensuring telehealth and telephone access in rural communities is particularly important," Bailey said in a statement.
The AMA delegates also adopted policies addressing structural racism and law enforcement tactics, with a focus on how racially marginalized and minoritized communities are disproportionately subjected to police force and racial profiling.
Opposing “excited delirium” diagnosis: A policy adopted by physicians, residents and medical students at the AMA delegate meeting opposes “excited delirium” as a medical diagnosis and warns against the use of certain pharmacological interventions solely for a law enforcement purpose without a legitimate medical reason.
The new policy addresses reports that show a pattern of using the term “excited delirium” and pharmacological interventions such as ketamine as justification for excessive police force, disproportionately cited in cases where Black men die in law enforcement custody, according to the AMA. The physician organization says current evidence does not support “excited delirium” as an official diagnosis and opposes its use until a clear set of diagnostic criteria has been established.
The AMA is against the use of sedative/hypnotic and dissociative drugs—including ketamine—as an intervention for an agitated individual in a law enforcement setting, without a legitimate medical reason.
Law enforcement use of crowd control weapons: The AMA strongly encourages prioritizing the development and testing of crowd-control techniques that pose a more limited risk of physical harm.
“Crowd-control tactics used by law enforcement at some anti-racism protests have been called a public health threat, with excessive use of force raising health and human rights concerns as well as undermining freedom of peaceful assembly,” says the report.
The AMA delegates adopted policy on less-lethal weapons that supports prohibiting the use of rubber bullets—including rubber or plastic-coated metal bullets and those with composites of metal and plastic—by law enforcement for the purposes of crowd control and management in the U.S. The policy also supports prohibiting the use of chemical irritants and kinetic impact projectiles to control crowds that do not pose an immediate threat.
The AMA policy recommends that law enforcement agencies have in place specific guidelines, rigorous training and an accountability system, including the collection and reporting of data on injuries, for the use of kinetic impact projectiles and chemical irritants.