In this environment, it should come as no surprise that for the second straight year, the 2018 Medical Economics Payer Scorecard shows that physicians are greatly dissatisfied with the policies payers implement, many of which cost them both time and money.
The healthcare system is too focused on reducing costs and improving payer bottom lines, says Stephen Marmaras, director of state and national advocacy for the Global Healthy Living Foundation, which aims to improve the quality of life for people with chronic illness.
“Physician autonomy and patient choice and overall patient outcomes fall victim to that prioritization in the system,” he says, adding that prior authorizations and fail-first medication policies are the results of a bottom-line focus by payers.
“I can get one medicine covered for a patient, but only if they try and fail another one first,” says Theresa Rohr-Kirchgraber, MD, FACP, an internist and founding member of the Doctor-Patient Rights Project, which advocates for doctors and patients driving care decisions. “It’s a hard concept to explain to patients that they have to fail a medication.”
The challenge for physicians is that there are multiple sources of interference. Each payer has its own rules and formularies, and state and federal regulations add another layer of frustration. So what can physicians do to fight back to retain their autonomy?
Experts say that physicians must align themselves with other like-minded individuals to make sure their voice is heard and their autonomy is protected either through legislation or payer policy changes. This advocacy includes working with patient groups, professional societies, and legislators to make a difference in how medicine is practiced.
Working with patients
“Many of the problems physicians face, such as opaque prescription drug formularies or burdensome prior authorization processes, create difficulties for patients as well as physicians,” he says. “And since patients outnumber physicians, having a well-organized patient group on your side amplifies your voice and raises both the visibility and persuasiveness of your argument.”
Physicians want to help their patients access the care they need, and this may require recruiting them to help educate legislators or regulators on how their care is affected by policy changes. “This does require you to sometimes educate and encourage patients to be aware of the broader environment in which care is provided,” says David Pugach, JD, senior vice president, public policy for the American Osteopathic Association. “Encourage patients to engage in the process when something impacts their ability to seek care. How they do that is up to the individual.”
Patient advocacy groups, such as the Global Healthy Living Foundation, and disease-specific groups, may also weigh in on policy related to their disease. For example, the American Cancer Society may advocate for changes in how cancer treatments are covered by payers. These groups can help both physicians and their patients identify who to contact and craft messaging.
But no matter the strategy, Rohr-Kirchgraber says physicians must work with patients to improve healthcare. “I think as a collective group, we can make a difference,” she says. “Patients can get a lot more accomplished with physicians alongside them than they could alone. We need stories from individual people and I encourage them to reach out and talk about it.”
Working with professional societies
“The old saying is true: There is strength in numbers,” says Barbe. “Physicians will be more successful in their efforts if they work through state medical societies, their national specialty societies, and local chapters. These membership organizations exist to serve their members and patients, and they want to hear from practicing physicians about obstacles they face in providing high-quality care.”
Pugach says phone calls from physicians about the same payer issue help direct his organization’s advocacy efforts and that they make a difference. “In public policy work, if we are not aware of the real-world impact of a policy change, we won’t know what to advocate for on behalf of doctors.”
Another way doctors can help with advocacy efforts is providing specific examples of how a particular policy affects patient care. Practice data can also help sway opinions in favor of doctors. “Changing processes that waste time and resources or those that impede public health policy goals are probably areas that are most responsive to good arguments and data,” says Barbe. “In fact, it is always a good idea to bolster your arguments with data, even if it is just from your own practice.”
Working with legislators
“One of the simplest things a physician can do is when there is a particular bill in their state on an issue, they can write an email to the sponsor of [the] legislation expressing support—that would be helpful for the sponsor,” he says. “The next step would be to write letters to the editor in local newspapers, and advocacy experts from professional societies can help you with that. The highest level of commitment is coming to the statehouse and testifying.”
Both state and federal issues should be followed by physicians, says Rohr-Kirchgraber. Federal legislation often influences state efforts, so getting involved in legislative efforts at the federal level can end up helping at the state level. Payers are regulated by state insurance agencies, so efforts must be made at the state level to affect decisions at the local level.
Keeping track of all the legislative changes and regulatory processes, and knowing which arguments are likely to sway legislators or regulators, is difficult for individual physicians to do, but if they work with their professional societies, they can stay updated and offer support, says Barbe. “No matter what the level of involvement, it is important for physicians to take time to inform themselves about the policy, the impact, the key decision-makers, and the legislative or regulatory status of the advocacy effort,” he says. “Newsletters and alerts and medical society websites are ready sources of this information.”
Making a difference
But doctors can absolutely make a difference, Pugach says, both with policymakers and private payers, if they get involved. He cites the increased flexibility in the MIPS program as one example of change. “I still don’t think the flexibility is enough, but continued input from physicians is critical,” he says. On the commercial payer side, he says, physician groups came together to voice opposition to a policy change reducing payments for evaluation and management services, and as a result of their efforts, the payer ultimately withdrew the policy. “There was strong data and the physician community was united and spoke with a singular voice.”
Barbe says that enacting change with private payers presents different challenges than policy issues because elected officials aren’t involved, but it can still be done. “The AMA, for example, has been directly engaged with national insurer organizations to encourage ‘right-sizing’ of prior authorization policies,” he says.
But to achieve victories like this, physicians must invest the time to advocate on behalf of their profession before it’s too late, says Pugach. “I’ve seen a couple of letters from solo practitioners who are just tired and frustrated,” he says. “Costs for the practice have gone up and the administrative requirements have taken their toll.”
But the letters came too late to make a difference. “To hear something two years after the fact, is hard,” he adds. “The more people that get involved prospectively rather than after the fact, the greater the impact.”