'People and policymakers are finally getting it': AMA President Dr. Jack Resneck Jr. on the fight to fix prior authorization, physician burnout

It's only been around four months since Jack Resneck Jr., MD, took over as president of the American Medical Association. In that time, the U.S. Supreme Court overturned Roe v. Wade, Congress took action on a bill to reform prior authorization for Medicare Advantage plans, and the nation charted its course out of the worst public health crisis in more than a century.

Becker's recently sat down with Dr. Resneck to speak about the AMA's Recovery Plan for American's Physicians — a five-prong initiative centered around reducing burnout — along with payer-provider commercial contract breaks and the role of the AMA in the wake of restrictive reproductive and gender-affirming care laws nationwide.

"We've heard a lot about recovery plans in the economy lately, and we think it's important to have one for [physicians] as well," Dr. Resneck said. 

Question: It's been just a few months since the AMA unveiled its physician recovery plan. What progress has been made since its launch? 

Dr. Jack Resneck: Prior authorization is really a unifying problem that everybody is facing, and I think people and policymakers are finally getting it. When I talk to policymakers and lawmakers about this now, they've all had their own story about a prior auth nightmare. They all have a member of their family who went to the doctor, got a diagnosis, came up with a treatment plan, went to the pharmacy and got rejected and told they couldn't get the medicine and start their treatment.

Recently in the U.S. House, we passed a bill to address prior auth in the Medicare Advantage program and increase transparency so we actually know what the health plans are doing. That now goes to the Senate, and we're working hard to get that across the finish line.

We're working in partnership with state medical societies around the country on this thing called "gold carding," which I think of like TSA PreCheck for prior auth. If you're a doctor who ultimately gets 90 percent of your services approved on appeal, and you're practicing evidence-based medicine, insurance knows who you are, and [the physician] shouldn't be subjected to this anymore — insurers should focus their efforts on the small number of people who they think are outside of that evidence-based medicine standard. It'll be interesting to see how that gets implemented in Texas and West Virginia.

We also have a variety of other states working on gold card legislation and around continuity of care — sometimes patients get a medication and are doing great, and then find out a year later the medication requires prior auth again. 

There are a number of pieces to this, and unfortunately in the commercial side we have to go state by state, but we are seeing a really accelerated pace.

Q: Residency slots haven't kept pace with growing enrollment in medical schools, largely due to a federally imposed cap from 1996 on support for residencies. What can hospitals and other healthcare organizations be doing in the meantime to address physician shortages as they await for the cap to be removed? 

JR: When we look at where we are with the workforce and our aging population, we know this is an issue and we know we need more physicians. In the last 10 years, fortunately, we have seen medical school expansions.

But residency training hasn't grown as fast, and we're essentially just narrowing the pipeline. We believe that Medicare caps need to be lifted and that not just Medicare, but all insurers, should play their part in this.

In the meantime, we have seen individual health systems and academic medical centers trying their best to work around this. Some places have used their own resources to create new residency positions at their own expense. We've also seen growth in state-funded residency positions, although that's been pretty limited. At Veterans Affairs, which has been a huge supporter of residency training, training programs have grown.

The reality is, it's quite expensive to train new physicians. Running an academic health system by its nature is a more expensive process than hospitals that don't do training. There's a lot of things that drive these expenses, but at the end of the day, we simply have to get more physicians approved. 

Q: Contract breaks between payers and providers have become an increasingly common issue around the country. Payers say the answer is more value-based care arrangements. Is that the best solution?

JR: Whether you're in a tiny solo practice, a small group or a hospital, the costs have increased a lot, particularly these last two years. Medicine, like the rest of the economy, is seeing a labor shortage that is costing practices a lot. 

On the Medicare side, for 20 years we've seen totally flat physician payment rates. On the commercial side, the insurance market is so consolidated. When you have so many markets where either one or two health plans is controlling up to 80 percent of the commercial marketplace, what's happening is you have insurers that are presenting take-it-or-leave-it offers that are less and less all the time.

It is not surprising to me that when presented with these no-choice contracts, physicians are finally reaching a point where they're saying, I can't support my own staff and keep the lights on with these contracts. While we're a supporter of having a diversity of payment models, and value-based contracts are certainly a piece of that, we really think it's important to have models where the people on the front end and the physicians delivering the care are engaged — that their lens is represented in the creation of them.  We have had specialties coming up with new and alternative payment models, but unfortunately, health plans and Medicare haven't adopted all of them yet. But I'm optimistic that we'll make progress. 

Still, there's going to be some doctors for whom, in their community or in their specialty, some percentage of their care delivery is going to need to be fee-for-service. We need a functional fee-for-service model that actually covers people's costs above practice. I think these breaks are just the natural result of the incredible concentration that we've seen on the insurer side, and it's not a reasonably competitive marketplace anymore because of that.

Q: How do you view the role of the AMA in the wake of the Supreme Court overturning Roe v. Wade?

JR:  When I jump into an area that may be politicized and controversial around the country, we do it in the same evidence-based way that we approach any other science topic. 

Politicians are not supposed to be the ones sitting on physicians' shoulders and in exam rooms when they're making decisions with patients. We grieved in the Dobbs case, as we have in several other abortion-related cases, about the importance of keeping politicians out of the exam room. 

What we've seen in the wake of Dobbs is just chaos in several of these restrictive states. We have laws from the 1800s that are coming back into force and interacting with new laws. There's confusion about what the rules even are, and in some cases, rules that don't fit with the practice of medicine in any way.

I'm hearing examples from colleagues in many of these states of things happening every hour: patients with an ectopic that's at risk of rupturing and there is no other way to treat them other than termination. Patients who have a miscarriage that has not completed on its own and is now septic and infected in their bloodstream.

Physicians are having to call hospital attorneys and say, 'Can I go ahead with what I need to do to save this patient?' And attorneys are saying, 'What percentage chance of death right at this moment is there?' If the doctor says around 30 percent, the attorney either says wait until you get to 50 percent or move ahead with taking care of the patient.

It's putting physicians in a terrible position based on ethical norms and the science that we bring to the table. We're having politicians really trying to insert themselves in this decision making, and it's getting worse. We've also spoken up around the states that are really targeting transgender teenagers and trying to make a lot of very strict rules about basic gender-affirming care supported by every major affected medical organization. 

It's troubling, but we're litigating, we're speaking up, we're doing everything we can to try to mitigate some of the negative effects.

Q: Physician wellness and reducing burnout are a key aspect of the AMA's recovery plan. As a physician and involved industry leader, how do you prioritize wellness? 

JR: It's at the core of everything, because we can't fix all these other problems if we're not actually finding joy in our work. 

When we first started talking about physician satisfaction as an important thing to measure, we got some looks several years ago from groups that were non-physicians and who were wondering, why are you talking about this? Now, there's a big evidence base that it actually affects patient outcomes at the end of the day, so we have to have a sustainable profession.

It's an amazing privilege to get to be a physician, but we have got to get these obstacles out of the way. I am disturbed by current burnout rates, but when I look into the data about the things that drive burnout, I'm actually in some ways reassured that some of these things are going to be fixable if we get the right policies in place. 

The difference between physicians who are happy and finding joy in their work and those who are burnt out are those who are supported by their system and who can provide good care to patients versus those that aren't.

One of the things we do for AMA members is measure burnout levels in their system and show them how much it's costing them when they have physician turnover. They quickly realize the importance, and we have data-driven solutions to how to get these burdens out of the way for physicians, even at the health system level.

We're getting traction and we're making progress, but the numbers are terrible in the wake of this pandemic. As the AMA we're ready to do that rebuilding, and we're leading it in a way that we hope is influential, science-based and a powerful voice for the profession.

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