AMA President on Fighting Prior Auth, Scope Creep, and More

Gun Rights

The president of the American Medical Association (AMA), Jack Resneck Jr, MD, met with Medscape editors to discuss pressing topics in healthcare. Resneck, a practicing dermatologist at the University of California San Francisco, had just come from an appearance on MSNBC’s “Morning Joe, where he addressed government interference in healthcare, having previously written an opinion for The New York Times about the Texas ruling on the abortion drug, mifepristone.

In an opening statement, he highlighted the AMA Recovery Plan for America’s Physicians that aims to fix prior authorization, reform Medicare payment, fight scope creep, support telehealth, and reduce physician burnout.

This interview has been edited for length and clarity.

If the AMA is concerned about government interference in medicine and gun control, why hasn’t the AMPAC stopped funding lawmakers who oppose women’s reproductive health and who have received strong endorsements from the National Rifle Association. For example, in the 2021-2022 cycle, the AMPAC gave $414,000 to Republicans , including House Speaker Kevin McCarthy (CA). Most if not all of these lawmakers are on the opposite side of these issues.

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Dr Jack Resneck Jr

Jack Resneck Jr, MD:  It’s a reasonable question. Our PAC operates independently from us, but obviously it’s there to support people who support our issues. We’re not a single-issue PAC and we don’t have a litmus test. I’ve spoken to many of the people you’ve mentioned and am never shy about talking about areas of disagreement and agreement.

For example, we have to fix Medicare and that has to be a bipartisan fix. We have to use the system that exists and talk with all members of Congress. We’re a nonpartisan organization. I will sit down any day, anytime to talk to anybody who is willing to work to advance the policies passed by our House of Delegates. I don’t think it’s in the interest of doctors or patients to cut off our relationships with a large group of members of Congress.

Statements make a point, but money seems to be the only language politicians speak these days. If the AMA were to tie its money to the positions it values, wouldn’t that be the biggest lever it could pull?

Resneck: I am going to disagree with you that PAC donations are the whole story. We don’t just put out statements. I’ve been on the Hill several times this year. I testified before the Senate on a bipartisan hearing about health plans misbehaving and publishing ghost networks [inaccurate health provider directories]. I had a really good conversation with Senators from both sides of the aisle. I’m not afraid to speak up when somebody is not aligned with our policy on the public health crisis of gun violence or abortion or anything else. But our advocacy work, our lobbying on the Hill, our physician leaders appearing on the Hill, media appearances to explain our issues to policymakers when they’re watching — all those things add up to have influence.

You can’t yoga your way out of burnout.

You mentioned physician burnout in your opening statement. Do you see any progress? Are you hopeful?

Resneck: I continue to be an optimist. We do a lot of work around burnout and the future of the profession after the pandemic under an umbrella called the AMA Recovery Plan for America’s Physicians , which includes pillars we have to fix to make the profession sustainable. The challenges are immense.  Physicians struggle with things that get in the way of what drew them to medicine in the first place, which is taking great care of their patients.

I talk to policymakers about the nightmare of prior authorization and how it used to just be for new, on-brand, high-cost drugs or procedures, and now it’s generics, which is completely ridiculous. The average physician is doing 45 a week, by fax often, and then having to do appeals and talk to somebody who isn’t in their specialty, may not be a physician, may never even have heard of the disease they’re treating. It’s outrageous.

But why I’m optimistic is that every lawmaker I talk to has had their own bad prior authorization experience or has a family member who was not able to get a drug renewed that they were stable on for their diabetes or other chronic disease.

The Centers for Medicare & Medicaid Services [CMS] put out two great rules this year to rein in prior authorization in Medicare Advantage plans. We’re seeing state legislatures do the same on the commercial side. We now have a bipartisan bill in Congress to potentially tie future Medicare payments to the rate of inflation, which is a reasonable request. That’s what hospitals, skilled nursing facilities, and hospices have had for years. That’s just so physicians can keep up with cost increases. We have laid the groundwork despite all the challenges and are doing the hard work to get this stuff fixed.

Is the primary method to fix prior authorization via lobbying lawmakers?

Resneck: We tried the gentle approach first. I personally led an effort where we sat down with the chief medical officers of many of the largest health plans in the country to find areas of mutual understanding.  We said, ‘Can’t we try to rightsize this?’ We weren’t saying it should vanish. I think we had six in-person meetings and hammered out an agreement.

We put out a consensus statement with the health plans and a number of other medical groups and they committed to reduce the number of things that require prior auth to protect patients with chronic disease who are stable on a medication, improving the electronic prior authorization process so physicians can do it in their workflow instead of finding out later after the patient goes to the pharmacy and gets rejected. We had a series of gold-carding — like TSA PreCheck for prior authorization — which basically says: These docs get 95% of their prior authorizations ultimately approved, [so] why make them jump through hoops?

They agreed to all that. I told the health plans that I will go on TV, hold your hand, sing Kumbaya and congratulate you for your progress. What happened? I have yet to be able to do that.

We had an announcement last month from a couple of health plans that they were going to reduce the numbers but we haven’t seen that happen yet. We’ve had to go to legislators because nothing else has worked. Our patients are suffering. Of the patients who show up at the pharmacy and get rejected, about a third never go back and get their medication after the doctor works for weeks to get the prior authorization approved.

I always get riled up talking about it [prior authorization].

There is a bill in Congress that hasn’t been able to pass. In the absence of a federal legislative fix for prior authorization, are you worried that you will have potentially 50 different fixes?

Resneck:  My choice would be to have a single rule that fixes all of this. I would love nothing more. But we have the system that we have, right? Congress and CMS actually have authority over Medicare Part D plans and Medicare Advantage plans and there’s some shared authority around the Medicaid program. Then it gets complicated with commercial ERISA [Employee Retirement Income Security Act] plans and who regulates those, and then you’ve got large and medium-sized group commercial plans regulated at the state level. Then a lot of patients get their health insurance through their employer’s commercial health plans and those are regulated at the state level.

Is it harder work to go to 50 states and get those bills passed to protect those patients? Yes. Am I thrilled that the AMA in collaboration with our state medical associations has the bandwidth to do that work? Yes.

The bill in Congress that you mentioned, actually passed — over 300 votes in the House. It got stuck in the Senate last year because of Congressional Budget Office (CBO) scoring [which] essentially said: Hey, if we free up doctors from spending hours faxing prior authorization forms, they might see more patients and that might cost the system money.

We thought that was a ridiculous argument so we’re going back to the Hill particularly now that CMS has advanced its rules to fix some of the problems that those bills address. The price tag might be scored a little less and we might get it through the Senate.

We’re going to keep working on all those fronts. If you ask doctors, as I do when I travel the country, ‘What’s your number one annoyance on top of trying to keep your practice open?’ Five or 10 years ago, it would be my electronic health record is not very good and wastes a ton of my time. That’s not entirely fixed, but it’s somewhat better. Today, their answer is: I am exhausted by the prior authorization fights for evidence-based things. It’s a lot of our work so I always get riled up talking about it.

Is the AMA involved in promoting AI technologies like ChatGPT or other similar tools to reduce burnout for physicians?

Resneck: One piece of addressing burnout is about removing obstacles, and you can’t AI your way out of burnout, as long as the obstacles are there. When hospitals and health systems realized that burnout was a problem and cost money because of physician turnover, what was their first attempt? It was wellness-focused — yoga during lunchtime, a gift certificate to Starbucks. But you can’t yoga your way out of burnout either when the obstacles persist.

We have been working with evidence-based approaches. We have helped health systems follow those plans and measure the burnout rates as they do it, and we’re giving out awards for those who have really reduced burnout among our physicians.

At its best, AI is an area where there is an enormous opportunity to make physicians work better. At its worst, we end up with tools that aren’t validated or use secret, proprietary data that we discover a year or two later have actually been doing harm to our patients.

A lot of our work in the AI space is focused on transparency. When I’m evaluating an AI tool, just like a drug or a device, I want to see a study in JAMA with a control group and a treatment group where I can see what the outcomes were and what data were used to train the AI tool.

Will it fix burnout? If doctors are in the position of picking AI tools without that data, it could worsen burnout.

Why should specialists join the AMA if they already pay for membership to their specialty and subspecialty organizations?

Resneck: I think we are a really good value for physicians and there is no substitute for what we do. There’s no organization with the bandwidth, the breadth of talented staff and physician involvement, who represent the profession on these major threats. It’s the AMA that Congress, the administration, or others call on. We are out there negotiating to make the world better for doctors and patients, and the more physicians we have as part of that work, the more credibility we have.

I’m proud that whether somebody chooses to write that check every year or not, our policy process represents every physician in this country. At our house of delegates, every state and national specialty society is there debating and representing their members, whether they’re AMA members or not. I really think it is helpful to individual physicians and to the AMA as a whole, the bigger and stronger we are. The specialty societies are our partners, they’re incredibly important. This is not an either/or; the same [goes] for state medical associations.

How do you think the reimbursement for Medicare and private insurance is going to affect how doctors practice — whether they stay employed, self-employed, or go part time?

Resneck: It’s one of the downstream consequences of Congress’ failure to adequately fund Medicare payment. We’ve had more than 20 years of flat payments to physicians as inflation cracks along, so physicians have endured a substantial cut at a time when hospitals and others are on automatic equation-based updates. Physicians aren’t asking for more than that.

Practices are beginning to struggle because they can’t keep up with their costs — whether it’s the months during the pandemic where they got slammed by not having patients come in the door and still having to pay their staff or these payments not keeping up with inflation.

Now, physicians are under a lot of pressure to sell their practices to hospitals or private equity groups or anybody else. We believe physicians should have the choice to practice in whatever environment makes sense for them, just as we think patients should have choices about whether they like being seen in small practices or larger multispecialty groups. There’s value in all of those. But I think the rapidity with which we have seen market consolidation, and the growth of private-equity takeovers of physician practices, without a lot of healthcare background or values imbued in those organizations, is something that concerns us. Medicare payment is a big driver.

Does the AMA have an official position on private equity purchasing of hospitals and medical groups? If so, what activities are you using to convince federal or state legislators to put more restrictions on private equity acquisitions in healthcare?

Resneck: We don’t want to tell any physician, “You should never sell your practice to any larger group, private equity, or anything else.” There may be marketplaces where there’s been so much insurance consolidation that it’s the only way for a practice to survive. And they can be very different ones in terms of how much they retain physician autonomy and medical decision-making vs some other behavior that is less appealing.

We have spoken up on overall market consolidation. We’ve been deeply involved in litigation and Federal Trade Commission work as insurance companies have tried to merge. We have spoken up about vertical integration around health plans and pharmacy benefit managers and pharmacies themselves. Practice ownership structures bring up some of the same issues when you have health insurers employing tens of thousands of physicians. It’s something that concerns us and that we continue to look at.

With the end of the COVID public health emergency, have you heard from members or written anything about the implications for changes in their clinical practice?

Resneck: We’ve known this has been coming for some time, but we didn’t know exactly when. Preparing for that eventuality has been important, and our teams have put a lot of work into thinking about the things that would naturally change without the existence of the public health emergency [PHE].

One big area has been the transformational impact of telehealth being covered. From the PHE perspective, that relates to Medicare but commercial health plans largely followed suit. It has been fantastic for patients. Now we’ve come back to a place where we can seamlessly integrate telehealth with in-person care and know when it’s appropriate for a patient to be seen in-person or virtually; without Congress’ action, this was going to be ripped away from Medicare beneficiaries at the end of the PHE. That was completely unacceptable and there are a whole series of related policies about telemedicine and digital health.

We don’t have a permanent fix. But Congress has stretched many of those coverages for months to years, and we’ll continue to work on that.

How influential are student/resident members in shaping AMA policy?

Resneck: I love talking to our student and resident members. The generation coming into medicine now is passionate. They have lots of thoughts about the position of medicine in society and what we need in the decades to come to provide great care. They are deeply involved in our policymaking process. Over the arc of my involvement in the AMA, medical students and residents got proportional representation in our house of delegates. They’re well organized in the policymaking process.

Sometimes they’re our conscience and they’ve done tremendous work around everything from equity to new technologies. I can’t think of doing this work without them. About two and a half decades ago, when we still had smoking on airplanes, it was the medical students section of AMA that noted that it’s ridiculous that row 12 [on the airplane] is the non-smoking row and row 13 is the smoking row. They got us engaged with the Federal Aviation Administration and others to pass policy before we had much broader tobacco regulation.

A topic that gets a lot of attention on our site is scope creep. Where do you see NPs and PAs fitting in the care team?

Resneck: This doesn’t always get covered in a way where it’s clear that physicians can hold multiple truths.

One truth is that physician assistants, nurse practitioners, respiratory therapists, pharmacists, and a long list of other clinicians involved in the healthcare team are important and valued by physicians. In my hospital, I work with a lot of those colleagues and I can’t imagine doing my job without them. At the same time, I am a strong believer that the physician who has many extra years of training and has the most knowledge is in the position to be the leader of that team. It doesn’t mean they need to do everything or be present at every moment, but ultimately they are responsible for supervising and leading that team.

What gets physicians upset, of course, is that we have settings where states pass laws that, in some cases, get rid of the supervision requirements and I see PAs and NPs practicing specialty medicine who have no training in that specialty.

There’s a reason we expect people to go to medical school for 4 years and do an internship and 3 years of residency — because it turns out that recognizing some of the complex diseases we treat takes that degree of training.

There are things that we can work on in a team-based way with PAs, NPs, and others that make sense. When we see things that we think threaten a patient’s health, such as totally independent practice, people holding themselves out as physicians who don’t have that training, we’re going to speak up.

We bookended with some nice, controversial topics but glad you asked about them.

Jack Resneck Jr, MD, disclosed no relevant conflicts of interest.

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