Give Us Less Heartburn: AMA to Health Insurers

What You Need to Know

  • Dr. George Harmon, the new AMA president, talked about treating patients with COVID-19.
  • Dr. Jack Resneck Jr. is the new AMA president-elect.
  • The AMA opposes insurer efforts to pay patients to switch to cheaper drugs.

The American Medical Association is trying to change some of the strategies health insurers’ use to manage care.

Members of the AMA’s House of Delegates voted at a web-based meeting this week to support new guidelines for “peer-to-peer” conversations and to block insurer efforts to use cash payments to change what drugs patients use.

A health insurer often has its own physician call an enrollee’s physician before deciding whether to authorize payment of benefits for a course of treatment that’s especially expensive or controversial.

An arm of the AMA, which is based in Chicago, said in a report on peer-to-peer reviews that the peer-to-peer review process is supposed to make health insurers’ prior authorization processes friendlier and easier for patients’ physicians to understand.

“However, for many treating physicians, P2P review simply represents another time-consuming and potentially detrimental use of [utilization management] by insurance companies,” the council concluded.

The AMA is now calling for:

  • Peer-to-peer reviewers to follow national medical society treatment guidelines, when those guidelines are available and relevant.
  • Insurers to suspend prior authorization requirements for new care arrangements and extend approvals for existing care arrangements during public health emergencies.
  • A ban on prior authorization requirements for a follow-on surgical procedure, or other follow-on invasive procedure, that’s related to some other procedure that either was approved by an insurer or did not require an approval.

In 2018, America’s Health Insurance Plans was part of a group of national health organizations that agreed to work together to improve the prior authorization process.

In spite of that agreement, “health plans have made little progress in the last three years toward implementing improvements in each of the five areas outlined in the consensus statement,” the AMA said in an announcement of the new peer-to-peer review policies.

Care Switching Payments

The AMA House of Delegates also approved policies objecting to any efforts by health insurers to use direct financial incentives, such as cash payments, to encourage patients to shift away from treatments recommended by the patients’ physicians.

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