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CHICAGO -- Should physician practices get paid for the time they spend on prior authorizations? Members of the American Medical Association (AMA) House of Delegates seemed divided on the idea.

Prior authorization "is something that's really become a burden," Andrew Cooke, MD, representing the Florida delegation, said Saturday at a reference committee hearing at the AMA delegates' annual meeting. Delegates were debating two resolutions that advocated for developing Current Procedural Terminology (CPT) codes to reimburse doctors for time spent on appealing denied claims and on filing for prior authorizations. "I do think we should support these two resolutions because they get to the heart of what we want, and that's to get paid for what we do and services rendered."

Megan Srinivas, MD, MPH, speaking on behalf of the Council on Medical Service, disagreed. "We don't want to undermine our current ... advocacy efforts," which focus on changing the prior authorization system, said Srinivas. "We focus on building coalitions with patient advocacy groups to emphasize the harm the prior authorizations cause patients. We would undermine that by saying we're okay with improper denials as long as we get paid for it. Moreover, it's unlikely that health plans would even agree to pay physicians for prior authorization, especially when most network contracts stipulate that physicians are subject to prior authorization requirements."

But Zuhdi Jasser, MD, of the Jasser Center for Comprehensive Care in Phoenix, who spoke for himself, had a different opinion. "As much as I completely sympathize with all the work that our AMA leadership is doing to build coalitions, why we can't have multiple tracks that say, "You know what, if we fail here, we are also going to advocate to be paid for that.' ... If track A through coalitions fails, we will now begin to ask to be paid for the time that we have, because it's no longer fee-for-service, it's fee-for-time."

AMA president-elect Jack Resneck, Jr., MD, speaking on behalf of the board of directors, said that while prior authorization is "overused, costly, inefficient, and opaque," the board still opposed the resolutions. "I don't want to do anything that legitimizes a broken process by being asked to get paid for something that is totally broken," he said. Resneck noted that the association had listed fixing the prior authorization process as one pillar in its Recovery Plan for physicians. "I'm tired of prior authorization, but we're going to fix it."

Delegates also discussed a resolution asking the AMA to advocate for legislation or regulations that would designate provider burnout as a repetitive stress injury subject to oversight by the Occupational Safety and Health Administration (OSHA). "We're very happy that the AMA has taken up the physician burnout issue and prioritized physician wellness, and all the work that they've done in this area," said Bonnie Litvak, MD, speaking on behalf of the New York delegation.

"The reason that the New York delegation is asking this to be looked at is because we need to use all tools available to us and look at ways that we can make this better, and having this, which is a repetitive injury, fall under OSHA may give our physicians some more protection, and it may also lend support for our health systems to really prioritize physician wellness."

The Women Physicians Section agreed. "We absorbed the collective problems day after day, and then all we do is we wash our hands in between going to patient rooms -- we are expected to be robots," said Anna Laucis, MD, MPhil, alternate delegate for the section. "But we're not robots; we're humans. So this should be recognized as a repetitive strain injury, especially in the context of the COVID-19 pandemic, repetitively dealing with life and death."

But Tatiana Spirtos, MD, a California delegate speaking on behalf of the PacWest delegation, said that her group was opposed "primarily because of our fear that making this an OSHA issue would then subject whatever injuries occur as part of Workers Compensation, and we feel that it's the wrong way to look at burnout as a work-induced injury. So for that reason, because we don't want to go down that rabbit hole, we're opposed to this resolution."

Liz Davlantes, MD, speaking on behalf of the CDC, recommended referral back to the committee for further study. While the issue of physician burnout "is in strong need of attention, and there are adverse affects from it, the use of the cited definition of repetitive stress and strain injury is less than ideal," she said. "This definition is clearly written for repetitive physical acts ... and is not an ideal definition for referencing the repeated psychosocial stressors leading to burnout related to poor mental health outcomes."

Instead, OSHA's "general duty" clause might be a better fit, she said. "The general duty clause requires the employer to furnish employees a safe place of employment, which is free from recognized hazards that are called 'likely to cause death or serious physical harm to employees'. It can be strongly argued that the stressors in many healthcare settings can lead to serious harm or death. So this definition might be more applicable. Long-term policy support for a specific national mental health standard similar to ones seen in and the would be ideal in addressing this kind of serious risk."

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