APA Unveils Prior Authorization Model Legislation

According to the AMA’s 2021 prior authorization physician survey, 93% of the respondents reported that prior authorization leads to delays in care. Further, 82% reported that issues related to prior authorization can lead to patients abandoning their treatments.

With the support of staff in APA’s Division of Government Relations (DGR), APA district branches across the country have started pushing for prior authorization reform, including in Maryland and New Jersey (States Push for Prior Authorization Reform). For members and district branches hoping to start the prior authorization reform effort in their own states, APA’s DGR team, with direction from an APA member work group, has developed prior authorization model legislation that can be introduced in any state.

Ginnie Titterton

“This model legislation has been informed by the clinical expertise of members as well as the legislative expertise of APA’s DGR staff,” said Debra Koss, M.D., a member of APA’s Council on Advocacy and Government Relations, immediate past president of the New Jersey Psychiatric Association (NJPA), and chair of the NJPA’s Council on Advocacy. “Combining their technical knowledge related to legislation with our members’ clinical knowledge has created a tool that is going to be useful in states across the country.”

The model legislation was unveiled during APA’s State Advocacy Conference in Minneapolis in October, during which 100 members from two-thirds of APA’s district branches learned about the state legislative process and APA’s priority advocacy topics, including improving access to crisis care, ensuring safe prescribing practices, and increasing access to care through the Collaborative Care Model.

This was the first APA state advocacy conference that Tichianaa Armah, M.D., attended. Armah is the chief psychiatry officer at Community Health Center Inc., an assistant clinical professor in Yale School of Medicine’s Department of Psychiatry, and president-elect of the Connecticut Psychiatric Society (CPS).

For Armah, one of the key takeaways from the conference was learning that APA staff are “ready and willing to help us to advocate locally for our patients and practices in a way that is far more meaningful than one could imagine,” she told Psychiatric News. “That became clear talking to the staff between sessions and learning about the ways they can help us initiate change in our communities.”

Crafting Prior Authorization Model Legislation

In creating the prior authorization model legislation, DGR staff worked with members of the Council on Advocacy and Government Relations’ Prior Authorization Reform Work Group, as well as members from NJPA and the Maryland Psychiatric Association. “Members were able to highlight the impact of prior authorization on patient care,” Koss said. “This led to the inclusion of essential elements in the model legislation that will prevent prior authorization in certain circumstances when it directly interferes with patient access to care.”

The model bill addresses numerous problems that psychiatrists have long reported in the prior authorization process. It prohibits prior authorization in several circumstances, including on generic prescription drugs, on any drugs that have been prescribed without interruption for six months, and on any long-acting injectable medication.

It also requires that all coverage denials be made by a physician in the same specialty as the prescriber, that all denials be eligible for an expedited internal appeal process, and that the insurer renders a decision within 48 hours of the requested expedited appeal process.

In New Jersey, which has a year-round legislature, the prior authorization reform bills (S 1794, A 1255) are continuing to move through both houses. Koss said the next hearing in the Assembly is expected before the end of the year. “We have broad support not only from the medical community but most importantly from the patient advocacy groups, who are organized around prior authorization reform, as well,” she said. She emphasized the importance of having broad support and working with multiple medical groups in state advocacy.

“So much of how we as physicians practice medicine is influenced by state-level legislation,” Koss said. “We also have many opportunities to advocate on behalf of patients at the state level because state lawmakers are increasingly attuned to the urgent need for improving access to mental health care.”

Fighting for Patients

Learning more about prior authorization reform at the conference was incredibly informative and inspiring, Armah said. She has been an advocate in her district branch and more recently the Community Health Center, testifying before committees about legislative packages that would improve mental health care in Connecticut with a focus on children, but she was unaware of APA’s State Advocacy Conference until earlier this year.

“There is a lot that I have learned during my own experiences advocating that was confirmed during this conference, but I also received new information that is going to be highly valuable,” Armah said. She said she received actionable, helpful tips, and each of the advocacy topics was relevant. She works in a Federally Qualified Health Center with an integrated model, so she knows firsthand how helpful the Collaborative Care Model and other forms of integrated care could be if such services were appropriately reimbursed. She is also already active on social media, but she wants to bring the social media training that was conducted at the conference back to CPS so that her colleagues can learn more about how to advocate effectively on social media.

She also made connections with fellow psychiatrists from across the country. One such connection was with Jonas Attilus, M.D., a second-year psychiatry resident at the University of Minnesota and an APA Public Psychiatry Fellow. Attilus, who runs a podcast titled “Social Medicine On Air,” helped to lead the social media training with APA’s social media manager, Luke Waldron.

“As psychiatrists, people are looking to us to speak, and what we say holds a lot of power,” Attilus told Psychiatric News. “We know our patients better than many lawmakers and other stakeholders, and we have to say what we think to support them.”

Attilus shared his own tips on using social media as an effective advocacy tool, such as sharing personal stories and what patients are experiencing, but always being careful not to reveal any identifying information.

He said that advocacy doesn’t just mean speaking with lawmakers. It also means ensuring everyone around a patient is educated about mental health and mental illness. School personnel, including coaches, also need to understand what impacts students’ mental health, he said. “We need to share our expertise because the more people who understand, the better off our patients are.”

Legislation intimately impacts patients’ lives in terms of access to care, and it also impacts how psychiatrists are able to treat their patients. “My advocacy has stemmed from my patients. I advocate because they depend on me and they ask me visit after visit to fight for them. It allows me to positively impact more lives than I can sitting in an office. It feels like my duty. It is not easy, but it is rewarding.” ■