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Paying physicians and their staff for their time spent on dealing with prior authorization requests and denials was a lively topic of conversation at Saturday's session of the American Medical Association (AMA) House of Delegates interim meeting in Orlando, Florida.

One of the delegates' reference committees considered a resolution submitted by the delegation from the American Association of Clinical Urologists (AACU) to "initiate prior authorization legislation aimed at Medicare Advantage plans, state Medicaid programs, as well as commercial payers, via model legislation, that allows for fair reimbursement for physician's time and that of their office staff when dealing with prior authorization." The reference committee's preliminary recommendation was to refer the resolution back to the AMA Board of Trustees for a decision.

Should the House of Delegates Weigh In?

Bill Reha, MD, of Woodbridge, Virginia, the delegate from the AACU and the author of the resolution, asked that instead of just letting the Board of Trustees decide what to do, the board should study the issue and report its findings back to the House of Delegates at the delegates' annual meeting next June, "so that the House of Delegates can weigh in on this important matter affecting all physicians before a decision is made."

But Maryanne Bombaugh, MD, speaking for the AMA Council on Legislation, said the council preferred to have the Board of Trustees act. "There are intensive and ongoing efforts at the AMA right now to address prior authorization," she said. "We have serious concerns that this resolution, if adopted, could have a detrimental impact on our prior reform efforts ... A critical component of [the AMA's] prior authorization reform effort has been the development of patient coalitions. The Council on Legislation is concerned with changing course; focusing AMA policy on a model bill that addresses only payment for prior authorization and not the impact on patient access to care could fracture these coalitions and impede our successful prior authorization reforms."

Brian Murray, MD, speaking for the New York State delegation, disagreed. "We understand the issues put forward about ongoing legislation and issues. But the reality is, this has been going on for a number of years. There are at least four or five bills out there regarding this; none of them are comprehensive. Going for a study and report back would not affect ongoing activity, as it is not directly drawing up a new bill or new direction. It's just looking at where we are reporting back to the House." Parag Mehta, MD, a fellow New York delegate, suggested that the resolution "could be seen as a tax on prior authorization, and may actually help as a deterrent to prior authorization, and may even ... push the path toward getting rid of prior authorization completely."

Alex Shteynshlyuger, MD, a New York City urologist who was speaking for himself, said that when it comes to getting rid of prior authorization, "I'd like to be idealistic, but after 20 years, we have to be realistic and practical, and ameliorate our suffering and financial bleeding."

Shteynshlyuger, who has previously floated the idea of creating a CPT code for time spent on prior authorizations, suggested that physician salary data from the Bureau of Labor Statistics could be used to figure out how to value physician time spent on the process. He noted that the Improving Seniors' Timely Access to Care Act, a bill now in Congress that would more tightly regulate prior authorization, "has not moved anywhere in the past 4 years" and would only affect Medicare Advantage, not Medicaid or commercial insurance plans.

Ted Mazer, MD, a delegate for California who was speaking for himself, urged caution with the resolution. "We don't know what the negative implications would be," he said. "Maybe we get paid for prior authorization work, but it comes off of something else. I think the focus needs to be on eliminating or severely reducing prior authorization and worrying about the negative impacts."

Pediatric Hospital and Unit Closures

Delegates were more in agreement on a resolution offered by the American Academy of Pediatrics (AAP) and the Society of Critical Care Medicine (SCCM) to give support to pediatric hospitals and pediatric units in the wake of many pediatric-related closures. The resolution, which the reference committee recommended for adoption with a few changes, called for the AMA to "recognize the closure of pediatric hospitals and units as a critical threat to children's healthcare access and quality" and to "build a national coalition with the American Hospital Association and other like-minded organizations to increase awareness on the issue of pediatric hospital closures and to develop strategies to preserve access to high-quality pediatric inpatient and critical care."

AAP president-elect Sue Kressly, MD, of Sanibel, Florida, who spoke for the academy delegation, said that "The long-term closure of pediatric care units across the country is hurting children's access. When my hospital closed its peds unit, a 1-month-old with RSV was admitted to a med-surg floor and cared for by nursing staff with limited pediatric experience. The patient's respiratory rate of 22, which is normal for adults, was not recognized as critical, and the child nearly died. This is urgent, and we thank you all for your support."

Katrina Saba, MD, a pediatrician from Oakland, California who spoke on behalf of the PacWest delegation, said that a found that "if every emergency room in the United States were fully prepared to treat children, thousands of lives will be saved, and the cost would be $11.84 or less per child. So although this is about emergency departments, it is a perfect and unfortunate illustration of why this resolution is so important."

Myo Myint, MD, of New Orleans, an alternate delegate from the American Academy of Child and Adolescent Psychiatry, offered an amendment on behalf of his delegation that added the words "including pediatric inpatient psychiatry units and pediatric psychiatry hospitals" to the resolution. "The U.S. pediatric mental health crisis is continuing to mean insufficient access to pediatric mental healthcare services," he said. "Pediatric hospital and inpatient unit closure, including the pediatric psychiatry hospital and inpatient unit closure, reduces access further and delays care, which can [exacerbate] the mental health crisis, and that can result in poor health outcomes."

Combatting Public Health Misinformation

Unlike the AAP and SCCM, whose resolution seemed destined for approval, AMA members from the New England delegation did not have as much luck with an emergency resolution on combatting public health misinformation that they attempted to introduce at the House of Delegates session early Saturday afternoon.

Their resolution sought to empower the AMA Board of Trustees to "appropriately utilize AMA resources to both proactively and reactively combat medical information," to have the AMA "develop a comprehensive strategy to proactively combat public health misinformation through evidence based advocacy, education, and strategic communications," and to have the association "work with federation members and other stakeholders to create rapid response capabilities to address medical misinformation that poses an immediate threat to public health."

Mario Motta, MD, of Salem, Massachusetts, who spoke for the New England delegation, said the emergency resolution was necessary because "never before have we faced possible disinformation from our own government agencies, if certain individuals take over health departments such as HHS [Health and Human Services] and the FDA." Motta appeared to be referring to Robert F. Kennedy Jr., a vaccine skeptic who is expected to play a prominent role in healthcare decisions in president-elect Donald Trump's administration.

"Our AMA was founded in 1847 specifically to promote science-based medical practice and to stop charlatans of that age," Motta continued. "And yet, here we are basically having to do the same thing ... If certain campaign promises are indeed kept, the past 100 years of progress in public health are in jeopardy. Many worried new parents may be swayed to forgo public health measures such as vaccines if encouraged to do so by our own HHS and the FDA."

Emergency resolutions require approval of 75% of delegates in order to be considered at the current meeting; this resolution fell short, garnering the approval of 382 of the 586 delegates present, or 65%.

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