BCMS Alliance

Why First Tuesdays?

By Martha Vijjeswarapu Texas Medical Association Alliance President

First Tuesdays at the Capitol began when Susan Todd, an Alliance member, advocated for a law requiring that all motorcycle riders wear helmets. While it was passed into law, the following session, the people opposing stood strong and it was reversed. This was proof that a conversation was needed at every session to remind legislators of the importance of issues. Following the success of First Tuesdays at the Capitol, First Tuesdays in the District was created to foster strong relationships and promote effective communication with legislators throughout the year. These programs offer an avenue to advocate for issues affecting the Family of Medicine and to gain support for our communities and patients. This year, First Tuesdays will be held virtually. There will be a noon briefing and an action plan given on the issues at hand to communicate with our legislators. Please plan to be a part of the action calls for your legislators. First Tuesdays have long been known as the time for white coats to show at the Capitol. This year, those coats may not be seen in person, but our voices will still be heard through Zoom calls, emails, and text messages to our legislators. When a medicine-related bill comes up on the House or Senate floor, they pull the file to see how local physicians and Alliance members stand. Did they weigh in with their support or opposition by phone, email, or with an office visit? If they don’t hear from YOU — their local constituents — then they assume we don’t care about the bill. Our voices do matter and they do make a difference.

TMA will provide all the information regarding the issues. Please pass this information on to the legislative offices. The avenue we have with TMA/TMAA for advocacy is not to be taken lightly. Let's use this opportunity for the Family of Medicine.

Martha Vijjeswarapu is the Texas Medical Association Alliance President.

The 87th Session of the Texas Legislature:

How the COVID-19 Pandemic Has Affected The 2021 Legislative Session

By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer

Never before experienced in the Texas Legislature’s 175-year history, the 87th Legislative Session is the first ever to require social distancing protocols, the wearing of masks and in some cases, a negative test result for COVID-19.

This Session kicked off at noon on Tuesday, January 12 with the Texas House and Senate chambers conducting the swearing-in of the elected members of both chambers. During previous sessions of the Legislature, both Chamber floors and galleries were packed with family and visitors to mark the occasion, but for this session, only a limited number of guests joined in the ceremonies. In addition, as is customary, members of the House of Representatives elected a new speaker, Rep. Dade Phelan from Beaumont, currently serving his fourth term as state representative for House District 21. Congratulations to Speaker Phelan, who becomes the 76th Speaker of the Texas House. We also congratulate a new State Representative from San Antonio, Rep. Elizabeth “Liz” Campos, representing Bexar County’s House District 119, the seat formerly held by now Senator Roland Gutierrez. On the Senate-side, senate members elected Senator Brian Birdwell of Granbury as Senate president pro tempore. The president pro tempore will act as acting governor when Governor Greg Abbott and Lt. Governor Dan Patrick are out of the state at the same time. Congratulations to Senator Birdwell as well as to a new member of the Senate from San Antonio, former Rep. Roland Gutierrez, now Senator Gutierrez, who represents the sprawling area of Senate District 19, the

seat formerly held by Senator Pete Flores.

Rules adopted by the Senate introduced COVID-19 protocols to be implemented for everyone during the first 60 days of the session. As stated, any person, including members of the Senate, entering the Senate Chamber, the Senate gallery or attending a Senate committee hearing, must first test negative for COVID-19. Members of the public are not required to take a COVID-19 test prior to entering the Capitol. Free testing is available, however, and individuals who test negative are given a wristband in order to enter the Senate gallery or Senate committee hearing. Additionally, wristbands will be given to individuals showing proof of vaccination. Adjustments to these rules could be considered in March.

The adopted rules of the House of Representatives do not call for strict testing protocols as outlined in the Senate. Basically, discretion on testing is left to the individual House members and to the public. All visitors to the Capitol may get tested, if they wish, at no expense to them. The state representatives have the right to require testing of anyone that comes into their personal office.

As with every legislative session, the only bill that must pass is the state budget. At the time of this writing, both the Senate and House have filed budget bills and committee hearings are underway.

A number of issues are being tackled this session. One committee that started working right out of the gate is the Committee on Redistricting. Normally, the work of this committee is conducted during the interim, but due to the COVID-19 pandemic, earlier in-person hearings around the state had to be postponed. The Committee on Redistricting has been holding regional, public hearings virtually via videoconference. In addition, members of this Committee await the data from the 2020 Census, also delayed by the COVID-19 pandemic, which is critical to the work of the Redistricting Committee. The Census data will show how the population of Texas has changed over the last decade. This information identifies changes in the number of congressional seats for the state, thereby providing key data for lawmakers to assess as they work to redraw house, senate and congressional district lines.

Among the issues prioritized as emergency items by Governor Abbott for the 87th Legislative Session, as presented during his State of the State address last month, are: 1) the expansion of broadband access; 2) funding police; 3) fixing our flawed bail system; 4) election integrity; and 5) civil liability protections for businesses, individuals and healthcare providers during a pandemic. Emergency items are fast-tracked during the first 60 days of the Session.

At the time of this writing, the February 2 First Tuesdays visits with our legislators are behind us and what has been different this session is that there are no trips planned to Austin for in-person First Tuesdays visits at the Capitol. Since the start of the pandemic over a year ago, Zoom meetings became the norm and replaced all in-person meetings. During the interim, TMA and BCMS joined forces with the TMA Alliance to participate in First Tuesdays in the District. These were visits with our state representatives from Bexar County, in their district offices. We were fortunate to visit with a couple of our legislators in person just before the pandemic hit. After that, BCMS and TMA held several visits with our legislators last Fall in preparation for the start of the 87th Legislative Session. Presently, we are actively participating in virtual meetings with our legislators and their staffs to advise them of medicine’s issues. Another change this Session is that the First Tuesdays visits are scheduled anytime and not held strictly on the actual First Tuesday of each month between February and May.

As with each legislative session, TMA prepares a legislative agenda which highlights key items of importance to medicine (the full agenda is available in this issue of San Antonio Medicine). Among the key items on TMA’s radar are: coverage expansion for the uninsured and underinsured; improve access to telemedicine services for patients; support of telemedicine payment parity; reduce health insurance prior authorization red tape; strengthen the state’s public health infrastructure; preserve health care funding in the state budget; ensure patient safety through team-based care (scope of practice); prevent taxation of medical billing services; preserve funding for medical residency and rural loan repayment programs; increase the Texas tobacco tax and create a tax for vape products; and retain Texas’ landmark medical liability reforms.

As your lobbyist and representative with our elected officials, I also work with the TMA lobby team, led by Dan Finch, VP of Advocacy, along with associate directors of advocacy, Troy Alexander, Michelle Romero and Clayton Stewart to keep our physicians informed on the status of medicine’s issues as key legislation on these items moves through the legislative process. In addition, as staff liaison to the BCMS Legislative and Socioeconomics Committee, I assist the physician members of the committee to track and monitor important legislation, coordinate visits with legislators and provide key details and alerts as information becomes available. Members of this committee are active participants in visits with our legislators.

Mary Nava is the Chief Government Affairs Officer at BCMS. To learn more about how you can participate in the First Tuesdays visits with our legislators, register at www.texmed.org/firsttuesdays and consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at mary.nava@bcms.org.

How to Advocate for Medicine: COVID Style

By Jenny Shepherd

For the last year, our world has been turned upside down and COVID has changed virtually everything, including how we advocate for medicine. What hasn’t changed is our need to do so…to stand up for science, to stand up for public health, to stand up for medicine. Never before has it been more important for the voice of medicine to be heard as the experts over the voices of influencers. How do we make that happen in our socially-distanced world?

First Tuesdays:

Learn about the pressing issues from Texas Medical Association lobby staff every first Tuesday February through May. It’s never been easier. Register on their website https://www.texmed.org/FirstTuesdays/, get a zoom link and sign in at noon to hear a short presentation on the legislation affecting medicine today along with a question-andanswer session.

Virtual Legislative Visits:

Visit with our Bexar County legislators virtually to discuss with them their priorities for medicine as well as talk about what is important to medicine. Pre-authorization hassles? Meaningful changes to Medicaid? You have a story to support the facts. Join the conversation and tell it.

Educate yourself:

Curious about what Texas Medical Association’s legislative priorities are? Their website has downloadable one-page summaries of almost every priority issue for the 87th Legislative session from vaping, scope of practice, maternal health and graduate medical education.

Get Involved:

The legislative committee for the Bexar County Medical Society meets the last Wednesday of every month to discuss legislative issues and works to strengthen bonds with our local legislators. Meetings are currently on-line so it has never been easier to volunteer your time to serve medicine. Use Social Media to Form Legislative Relationships:

Follow your legislator on Facebook and Twitter. It’s a great way to get to know about your elected official. Not only do you get a chance to find out what is important to them and what they are doing in their district, but they know you are interested in them. Retweet, like, share and comment showing your support for what they are doing especially when it relates to medicine; these are all excellent ways of letting them know the family of medicine is paying attention. And don’t forget to say “thank you” publicly for their time and support for medicine’s agenda.

Spread the word about the TMA and medicine’s legislative and health priorities:

Use your public platform to be the voice of what is important for public health, for patient care and for Texas physicians. In a time where there are many opinions to be heard, let the family of medicine be at the forefront.

Join TexPac:

Learn more about medicine’s political action committee and consider becoming a member. Your membership in TexPac helps to elect the right candidates for medicine; not Republican or Democrat, but medicine friendly. When you start with legislators who have an open mind to the needs of medicine, it is easier to enact legislation that meets the needs of medicine.

Finally, make 2021 the year you commit to becoming an advocate for medicine. If you’ve never ventured into realm of medical advocacy, try something new. If you are already active, consider doing more. The voice of medicine, your story, your needs have to be shared. If you aren’t willing to talk, legislators will be listening to someone else.

Jenny Shepherd, past president of the Bexar County Medical Society Alliance, now serves as Vice President of Legislative Affairs for the Texas Medical Association Alliance. Additionally, she is a member of Texas Medical Society’s Council for Legislation and the TexPac Board.

The No Surprises Act

By Ezequiel Silva, MD

Surprise billing occurs when a patient receives a bill for the difference between an out-of-network provider charge and the amount covered by the patient’s health insurance. Forty percent of adults report having received an unexpected medical bill during the preceding 12 months, and 13% of these bills exceeded $2,000. (Reference: KFF Health Tracking Poll (conducted August 2328, 2018). Available at: https://img.datawrapper.de/A5lJn/full.png. Accessed January 25, 2021).

Policymakers have long been aware of the stress unexpected bills cause patients and have been eager to craft a solution. Several states, including Texas, have laws to curb surprise billing. But state laws apply only to health insurance plans that are fully regulated by the state. This means that most health plans in Texas are not impacted by state law. For example, plans that are covered by the Employee Retirement Income Security Act of 1974, so-called ERISA plans, are regulated by the federal government. To address surprise billing in federally regulated plans, Congress passed the No Surprises Act (henceforth, referred to as the ACT), which was signed into law at the end of December 2020 and goes into effect on Jan. 1, 2022.

Enforcement of federal plans to which the law applies shall be the responsibility of the Department of Labor. The law allows the federal government to impose penalties of up to $10,000 per violation. As with most new laws, the statutory language provides a framework for implementation, but the specifics of implementation will be defined by regulations to be published over the next year and beyond. Usually, proposed regulations are subject to public comment, which heightens the need for physicians and their practices to understand the requirements and details of the law.

The law seeks to take patients out of the middle of payment disputes between insurance carriers and physicians. In general, insurers and employers have favored the use of benchmark payment standards to determine payment amounts, whereas providers have favored an independent dispute resolution (arbitration) process to settle disputes. In the end, the Act does not use a benchmark standard. Instead, the law requires voluntary negotiations between providers and insurers with arbitration as a backup, should those negotiations fail.

An important goal of the new law is patient protection from surprise bills. The law seeks to achieve this goal by limiting patient cost-sharing and providing greater transparency on costs. The law mandates that patients who receive services from an out-of-network provider may be held responsible only for the cost-sharing they would have incurred from an in-network provider. The requirement for greater transparency to patients comes in the form of an advanced explanation of benefits prior to a health-care service. In addition to a good faith estimate of costs and cost sharing, patients must be informed whether their provider is in network or out of network. When the provider is outof-network, patients must be instructed on how to find an in-network provider for their service. Insurers must maintain up-to-date provider directories, enable price-comparison information and a web price-comparison tool. In instances where charges are substantially higher than the good faith estimate, patients may directly invoke the independent dispute resolution (IDR) process.

These consumer protections apply to care in both emergency and non-emergency settings. Emergency care protections apply regardless of whether the facility is in-network or out-of-network. They also include protection on all emergency services from initial evaluation and treatment until the patient is stabilized and able to consent to transfer to an in-network hospital. These emergency-related protections also apply to out-of-network air ambulances, but they do not apply to ground ambulances.

Consumers are also protected from surprise billing for non-emergency services provided by an out-of-network provider during care at an in-network facility. This includes ancillary services, such as those provided by an anesthesiologist, radiologist or pathologist. It also includes unexpected specialty care such as care from a neonatologist or other specialist. The ACT allows patients to voluntarily accept exemptions to the surprise billing limitations, but this requires that the patient knowingly and willfully agree to use an out-of-network provider.

We have established that patients are removed from payment disputes between providers and insurance carriers, but how are these disputes resolved? The details on the independent dispute resolution (arbitration) process have important, practical implications for physician practices. Before entering arbitration, 30 days must pass in order to allow for private negotiations between providers and insurers. Should those negotiations fail, either party then has four days to request arbitration. If no arbitration is requested during those four days and the parties fail to reach an agreed amount, then the provider must accept the amount paid by the insurer for the claim. Conflict-of-interest rules apply to the arbitrator.

Forthcoming regulations may define more specifically how the independent dispute resolution process occurs, but for now, the law establishes that arbitration shall be “baseball style.” Under this style of arbitration, each party proposes a single payment amount and the arbitrator must select one or the other. In other words, the arbitrator may not choose an amount in between the two proposed amounts. Once the arbitrator reaches a decision, that decision is binding. However, continued negotiation is allowable.

Providers may batch together multiple cases into a single arbitration proceeding. This is allowable only if the cases involve the same insurer, provider and medical condition. In addition, these cases must have occurred within the same 30-day period. The Act includes provisions to prevent overuse of the arbitration process. For example, the losing party must pay the administrative costs of the arbitration proceedings. Moreover, the party that initiates the arbitration process may not take the same party to arbitration for the same service for 90 days after a decision has been reached.

Arbitrators must consider several factors in reaching their decision. These factors include the following, as they relate to the provider: level of training or experience; quality and outcomes; market share, prior contracted rates, and good faith efforts (or lack thereof) to join the insurer’s network. Regarding the insurance provider, the arbitrator may consider market share and median in-network rate paid. Other considerations include patient acuity and complexity, teaching status, case mix and scope of services performed. The arbitrator may not use government payor rates, such as Medicare.

The effects of the new law remain to be seen, and continued study is required. For example, the Act requires regular reports to Congress regarding the outcomes from arbitration cases, as well as the general impact of the law. Further, the law requires reporting on impacts on health costs, provider consolidation and access in rural areas. The Government Accountability Office is required to prepare reports on (1) the law’s impact on network adequacy, (2) impact on provider payment rates, and (3) reports on the independent dispute resolution process, including relationships between providers and private equity firms.

The impact of the Act on local practices remains to be seen. What effects, if any, will the law have on contracted rates, network adequacy and patient out-of-pocket costs? It will be important for practices to understand the Act and its specific requirements to inform questions of this sort. Along the way, BCMS, TMA, and AMA will be important conduits to influence the evolving regulations around this law.

Ezequiel "Zeke" Silva III, MD is a member of the South Texas Radiology Group and Co-Chair of the AMA Digital Medicine Payment Advisory Group, Chair of the AMA RVS Update Committee (the “RUC”), and Dr. Silva is on the Board of Directors of the Bexar County Medical Society.

“Sin” Taxes on Tobacco Should Match State Expenditure

By John J. Seidenfeld, MD

We are aware of the terrible toll of disease, disability, and death from the use, combustion, and inhalation of tobacco and byproducts such as nicotine and countless hydrocarbons. Illnesses caused include atherosclerosis affecting all organs, not the least of which the heart and brain; chronic obstructive pulmonary diseases; and cancers of many organs in addition to the lungs and oral cavity.1 Recently, vaping of tobacco products has added to the disease burden which many predict will be equal or worse than that caused by cigarettes. In Texas there are some three million cigarette and vape users.

The societal and budgetary costs attributable to smoking are high. The costs show a significant state shortfall in terms of work missed, healthcare costs and opportunity costs. The individual costs over a lifetime and per year for Texas smokers are shown in Table One.2 It will be a few decades before we have data for vaping, but many pulmonologists predict similar adverse effects over time.

Table One. Societal Costs Related to Smoking in Texas and State Rank

How do we determine taxes for the significant expenditures that smokers incur? Texas taxes cigarettes, according to the comptroller, $1.41/package as excise tax and $0.34 as sales tax. Vape products have no current excise tax and only sales tax. In addition, the Federal government adds $1-2 depending on the size of the cigarettes. On average, a package of cigarettes costs $5.78 in Texas.3 In Australia, the cost of a pack of cigarettes is $27 USD and in Mexico $3 USD. Texas legislators voted down an attempt to add an excise tax for vaping in 2019, and as of today these products still are not assessed an excise tax. Overall, tobacco use costs over 90 times the amount that we tax on smoking in Texas (Table 2), adding to the yearly subsidy we get from big tobacco after the lawsuit at the end of the last decade, and we still have a huge shortfall.3a

*Data from Wallethub.com 2020, US dollars, from CDC and US Bureau of Statistics ** Lowest numeric rank means lower income, lower opportunity cost, and lower health care spending by Medicare and Medicaid

Table Two. 2019 Cigarette and Tobacco Taxes vs Costs in Texas

The Texas Public Health Coalition (TPHC), made up of thirtyone health care organizations in the state including the Texas Medical Association and BCMS, is in favor of 1) banning all characterizing flavors including menthol in E-cigarettes, which younger users favor, 2) increasing taxes on conventional cigarettes as well as imposing an excise tax on E-cigarettes, and 3) strengthening enforcement measures on retailers.4

What is the broader purpose of raising funds through excise, Pigouvian,5 and sales taxes on tobacco and related products? Our duty as health care professionals is to help prioritize recommendations to policy proponents such as the TPHC, lobbyists, and legislators.

The major areas to support are: • Prevention of tobacco product use disorders, helping youth make sound healthy judgements, and immunizing to prevent further infections of the lungs and affected organs

• Education of health care students and workers, counselors, and youth

• Enforcement of tobacco use, vaping, age limitations, and tax regulations

• Research into use disorders and tobacco related health consequences

• Treatment of tobacco and vaping related disorders

Prudent citizens and health care professionals advise and advocate for a) additional taxes as compensation for the state’s expenditures on the costs of tobacco and vape use and abuse, b) protection of youth from marketing directed actions that lead to a lifetime of tobacco or nicotine use disorder, and c) leaders who are guided by fiscal and scientific guidelines in future taxation legislation.

John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee. References and links 1) https://www.cdc.gov/tobacco/data_statistics/fact_sheets/ 2) https://wallethub.com/edu/the-financial-cost-of-smoking-bystate/9520 3) https://comptroller.texas.gov/about/media-center/news/2019/ 190904-sales-tax.php 3a) https://www.dshs.texas.gov/tobaccosettlement/pay2020.aspx 4) https://static1.squarespace.com/static/ 5) https://www.taxfoundation.org

Prior Authorization Shenanigans

By Neal S. Meritz MD

Doctors continue to shoulder the burdens of the Prior Authorization process, but that might all change if proposed bipartisan legislation becomes law this year. Medical Economics,, reports that at least 30 to 45 minutes are required to complete each individual Prior Authorization, which totals 20 plus hours per week per practice. This time is unreimbursed and it is now estimated to cost over $68,000 a year for every practice. It is a labor-intensive procedure for physicians, as denied requests necessitate manual intervention resulting in subsequent practice cost increases. Denials sit unworked as they often require multiple letters of documentation and many telephone conversations. Hold times are staggering, often lasting up to an hour. An authorization denial means no payment for the physician and a refusal of coverage by the insurer for the medication or the procedure for the patient.

Prior Authorization is a system invented by health insurers that requires physicians to obtain advance approval for prescription medications and medical procedures from a health care plan before delivery to the patient. A refusal by the insurance company does not deny or reject the medication or service; it simply states that the insurer will not pay. Health Care Plans contend that Prior Authorization programs are important for controlling costs and avoiding unnecessary or non-standard care.

Cost Control began in the 1950s with concerns about increasing hospitalizations. Medicare and Medicaid legislation in the 1960s necessitated the creation of Utilization Review committees. These usually evaluated the appropriateness of hospitalizations as well as problematic physician behaviors. Gradually, this evolved into a program called Prior Authorization, a process designed to provide patient protection and cost savings. In theory, these concepts were seen as a benefit to consumers because the result would be the prevention of unnecessary procedures and the avoidance of expensive brand name medications when cheaper generic alternatives exist. Continuing, some diagnostic studies and some medications deemed inappropriate by the insurance company would also be subject to Prior Authorization requirements.

Insurer related shenanigans significantly impact patients, with interruptions and delays in treatment being very common. The patient must figure out whether the process is stalled because of the doctor, the pharmacy or the insurance company. Patients are forced to forego necessary treatments in order to avoid the Prior Authorization unpleasantness, meaning treatments must often be abandoned. A survey conducted by the AMA in 2018, reported that 92% of doctors agreed that Prior Authorization harms patient access to care by 92%!

Physicians are united in their insistence that the Prior Authorization system must be reformed. The AMA has developed a concerted program to encourage changes. Minimizing care delay is crucial, as these frequently result in potentially unnecessary adverse patient events. In addition, the volume of Prior Authorization demands for prescriptions and medical services has steadily increased. Utilization management requirements must be applied by insurers more rationally and judiciously. Regular reviews should eliminate services and medications which are unnecessarily subjected to Prior Authorization. Time required might be shortened considerably by using online tools and algorithms for rapid turnaround. Transparency in communication between insurers and providers must be improved, possibly by creating an NIH panel not affiliated with insurers in order to avoid a conflict of interest. Continuity of patient care should be deemed critical, with special attention regarding the avoidance of interruptions and delays. Finally, the adoption of electronic Prior Authorization transactions based on existing national standards could significantly improve the process for everyone involved.

U.S. Representatives Suzan DelBene (DWA), Mike Kelly (R-PA), Roger Marshall MD (R-KS), and Ami Bera MD (D-CA) introduced HR 3107 in June, 2019. This bill would require Medicare Advantage Plans to streamline and standardize Prior Authorizations and improve transparency in health insurer programs. The bill is called the Improving Seniors’ Access to Timely Care Act, and it now rightfully has the bipartisan support of 219 members of the House of Representatives. In December, 2020, this legislation was introduced into the Senate by John Thune (R-SD) and Sherrod Brown (D-OH). The bill also seeks to establish an electronic Prior Authorization (ePA) system in order to approve medical services and prescriptions in a more timely manner. Reviews by qualified medical personnel would be required, and beneficiaries would be protected from disruptions in their care.

Here in Texas, the Texas Medical Association (TMA) has been active in the encouragement of Prior Authorization legislation. Governor Greg Abbott signed SB 1742 in June, 2018, sponsored by Senator Jose Menendez (D-San Antonio). This bill requires greater transparency involving Prior Authorization procedures, and it mandates that utilization reviews be conducted by a Texas-licensed physician in the same specialty as the requesting physician. Two physicians in the Texas State Legislature, Greg Bonnen MD (R-Friendswood) and Dawn Buckingham MD (D-Lakeway) have proposed a bill mandating that insurers post the health services that require Prior Authorization and that explain how it works. This includes a list of documentation the physician must provide. Senator Menendez and Representative Julie Johnson (D-Carrollton) are proposing the elimination of Prior Authorization requirements for benefits already demanded by the State of Texas such as mammography, prostate cancer screenings and diabetes supplies.

These legislators, both Federal and State, are to be commended. Their efforts are a good start though they not nearly enough. Reforming the Prior Authorization process is a formidable task; insurers have absolutely no incentive to change their current practices. Obfuscation, confusion, and bureaucratic inefficiency have always been insurance company tactics when dealing with physicians. It seems that the object of the insurance company is to collect premiums and to not pay claims. The Prior Authorization system is onerous, time consuming and very expensive to physicians. It is potentially devastating to patients. It does make more money for insurers. The efforts of the AMA and the TMA and the work of the involved legislators are supported by all independent physicians, and there must be continued aggressive activity to reform the Prior Authorization system.

Neal S. Meritz MD is a retired Family Medicine physician and a member of the Bexar County Medical Society Publications Committee.

As if COVID-19 was not enough to stress the health care system, the Prior Authorization (PA) burden is growing and making it difficult for physicians to take care of their patients. During this pandemic, many private practices were not able to survive and had to close; others had to furlough or lay off support staff. Prior authorization was a nightmare even before COVID-19 and its impact during the pandemic is intolerable for patients and physicians.

Physicians continue to describe the prior authorization process as an extremely frustrating process that hurts their patients. For example, in my wound care practice, a delay in prior authorization could potentially delay healing. There is evidence that once a diabetic patient has an amputation, they have a mortality of 68% within five years. It is higher than the mortality of breast cancer, prostate cancer, and lymphoma combined.

Over the last five years, the vast majority of Texas physicians (87%) and AMA physicians (88%) say that they have seen an increased burden as a result of the PA process, and 69% of Texas physicians describe it as very burdensome. The number of prior authorizations required for prescription medications (85%) and medical services (80%) continues to increase, inversely impacting the access to care for patients.

With decreasing reimbursement and increasing overhead to obtain prior authorization, it becomes a perfect scenario for the closure of many solo private practices. If solo private practices close, again, the access to care decreases. The physician's private practice office is the lowest cost center in the complex health care system.

It is critical to advocate and educate our legislators on these prior authorization issues. We have a chance to make a difference. Due to COVID-19, the Texas Medical Association has arranged all first Tuesdays at the Capitol as virtual events (https://www.texmed.org/ FirstTuesdays/). Please use this opportunity to connect to our legislators, so you can advocate on behalf of our patients from the comfort of your home or office.

There was already a shortage of physicians, but now, due to the global pandemic, the shortage is getting worse. In this already stressed environment of COVID-19, physicians had to spend hours on the phone to get proper care for their patients. On average, practices complete 33 prior authorizations per physician per week. Physicians and their staff spend an average of almost two days (14.4 hours) each week completing prior authorizations. 36% of physicians nationally and 48% of physicians in Texas report that they have to hire staff just to work on prior authorizations.

Most patients do not realize how much work their physicians put in behind the scenes to authorize care with insurance companies. Most physicians get multiple denials before finally getting approval. 85% of Texas physicians report delayed access to care and 81% report interrupted continuity of care as an outcome associated with these prior authorizations. 78% of physicians report that patients abandon treatment due to prior authorization problems. Even worse, 35% report delayed care leading to serious adverse events. The AMA survey shows that 16% of physicians report that a prior authorization led to a patient’s hospitalization, which unnecessarily increases the cost to the health care system.

Another problem with the prior authorization process is that there is a wait time for any response from the insurance company. 64% of physicians reported the wait time of at least one business day, while 29% reported waiting at least three business days. I recently testified at an AMA interim meeting that, if insurance companies require prior authorizations, they should make staff available 24 X 7 to process approvals. This 24-hour availability will at least improve the timing for the decisions and hopefully decrease serious adverse events for the patients.

Delays in obtaining prior authorization also cause problems with discharge planning for patients. During COVID-19, it becomes a problem when most hospitals do not have extra beds, and patients who have to be transferred to another facility require a quick turnaround.

In summary, prior authorizations are problems for both patients and physicians. Delayed care is unnecessary and should not be allowed. Most of the time, the decisions involved with the prior authorization process are made by someone who is not familiar with the patient or by someone who is not in the same specialty. Unfortunately, apart from patient care delays, prior authorizations also increase the cost for the patients and the health care system.

Prior Authorization Delays and Undermines the Best Patient Care

By Jayesh Shah, MD

Jayesh Shah, MD, a wound care specialist certified in Internal Medicine and Undersea and Hyperbaric Medicine, is a member of the Board of Trustees of the Texas Medical Association.

Resources Doctors say that delays are hurting patient outcomes https://www.medicaleconomics.com/ view/prior-authorizations-negatively-affect-care https://www.ama-assn.org/system/files/202006/prior-authorization-survey-2019.pdf

2020 TMA Survey on Prior Authorization 309767 Prior Auth Data Sheet Onepager.pdf Shah JB, Sheffield P, Fife, Textbook of Chronic Wound Care, Best Publishing 2018.