AMERICAN MEDICAL ASSOCIATION ORGANIZED MEDICAL STAFF SECTION

 Resolution:  A11

Introduced by:      Matthew D. Gold, M.D.

 Subject:                 Reimbursement for Preauthorization Work

 Referred to:           Reference Committee      

                              (xxx, Chair)

 Whereas, Improving health care quality, access, equity, and cost-effectiveness are AMA strategic priorities; and

 Whereas, The procedures collectively known as preauthorization for third-party payment of physician-recommended medications and procedures have become a pervasive factor in the delivery of health care; and

 Whereas, By various devices, preauthorization has increasingly demanded time and effort beyond medical economic justification and become solely based on raw cost containment alone, as evidenced by lack of discrimination in its various forms and applications (e.g., automated telephone lines not specifying which choice should be made for preauthorization; repeated requests for basic data at each level of contact; delegated prescription management services who are once removed from the preauthorizing third party without specifying accurate directions where to contact; asking questions already present on the original script or requisition) ; and

 Whereas, The effect of pervasive and obstructive procedures of preauthorization is one of diversion of medical resources of time (of doctor and staff) and expertise needed in the health care system for the optimal care of patients; and

 Whereas, Delay and/or denial of optimal medical care as determined by qualified health care providers, who are required by law to undergo education and employ their direct clinical experience as demanded by individual patient needs, have the effect of compromising that very directive such as frequently leading to the reduction in the patient’s  treatment and /or compliance; and

 Whereas, It is the duty or the profession, and policy of our American Medical Association (AMA), that we should advocate vociferously for our patients; and

 Whereas, The proliferation/escalation of the abuse of preauthorization has occurred despite repeated statements of policy by our AMA, and the Organized Medical Staff Section, against the excessive use of cost-containment measures that obstruct good medical judgment and care; and

 Whereas, Our AMA has affirmed the right to “fair compensation” for a physician’s administrative burden under managed care, including if not limited to the process of preauthorization; and

 Whereas, the evolution and expansion of those administrative burdens has continued to accumulate at a rate that cannot fairly be reflected in existing methods of measurement (e.g., RBRVS practice component); and

 Whereas, The  preauthorization process costs the physician and his/her staff time and the contribution of the physician’s professional expertise in a redundant fashion; and

 Whereas, There is currently little or no disincentive to third party payers to desist from this form of cost containment, again against AMA policy; therefore be it

 1.     RESOLVED, That our AMA will foster, via regulatory or legislative means, creation of a billable code or equivalent mechanism (beyond RBBVS) for the professional time and office expense involved in each preauthorization encounter; and be it further (D)

 2.    RESOLVED, That this reimbursement be mandated and proportionate to the physician’s value in face to face patient interactions (but not less than a quarter of an hour) (D)

 Resolution:  A11

Introduced by:      Matthew D. Gold, M.D.

 Subject:                 Medical Liability of Third Parties

 Referred to:           Reference Committee      

 Whereas, The practices of mandating preauthorization requirements for prescription medications; using excessively stringent criteria for certain widely performed tests and procedures; and using first-line reviewers unqualified to render competent judgment about clinical appropriateness appears to have escalated; and

 Whereas, Numerous inefficiencies employed in the process of preauthorization serve no apparent purpose other than to discourage prescribing/ordering of medications and tests (e.g., automated telephone lines not specifying which choice should be made for preauthorization; repeated requests for basic data at each level of contact; delegated prescription management services who are once removed from the preauthorizing third party without specifying accurate directions where to contact; asking questions already present on the original script or requisition); and

 Whereas, The proliferation of said preauthorization has increased to the point of interference in the efficient delivery of quality medical care as practiced by the vast majority of medical practitioners; and

Whereas, The cumulative effect of such preauthorization procedures is an intrusion into the practice of medicine to the point of constituting the practice of medicine itself by non-professionals, non-physicians, and/or non-treating physicians ? or those unqualified to understand the individual circumstances (e.g., allergies, co-morbidities, other patient-centered factors) of a given patient situation; and

Whereas, Our AMA has consistently advocated responsibility be assigned to, and legal liability be allowed for, third party health plans/payers (including ERISA plans) whose negligence results in patient injury or damages  due to their policies, procedures or administrative actions; and

Whereas, Our AMA has also affirmed and reaffirmed “the portion of its existing model state legislation that calls for certain elements of utilization review to be defined as the practice of medicine;” and

Whereas, The Massachusetts Medical Society has adopted the position that “decision-making regarding preauthorization of payment for medically necessary services and treatment is the de facto practice of medicine, and those involved in those reviews should be held liable for bad outcomes and in malpractice actions stemming from delay and/or denial of care;” therefore be it

 RESOLVED, That our AMA foster legislation at the national level In the 112th Congress (2011-12)  that defines third party (including ERISA plans) policies, procedures or administrative action – including decision-making regarding preauthorization of payment for medically necessary services and treatment – as the de facto practice of medicine, and that those involved in those reviews should be held liable for bad outcomes and in malpractice actions stemming from delay and/or denial of care at the state and/or federal level in legal or alternate resolution settings.