Medicare Pay and Prior Authorization Among Priorities for AMA President-Elect

The American Medical Association (AMA) House of Delegates (HOD) meeting in Chicago this past week featured discussions on a wide variety of issues, from Medicare payment rates for physicians, to wheelchairs on airplanes, to "legacy" medical school admissions. Leading the main sessions was HOD Speaker Bruce Scott, MD, an otolaryngologist from Louisville, Kentucky, though his tenure as speaker is ending as he steps into another big job at the AMA: president-elect.

MedPage Today (MPT) Washington Editor Joyce Frieden spoke with Scott -- who previously served as HOD Vice Speaker and as a member of the AMA Board of Trustees -- on Thursday to learn more about how he ended up in AMA leadership and what his hopes are for his tenure as AMA president. The interview, which was conducted with a public relations person present, has been edited for length and clarity.

MPT: Thanks for being with us today! Tell us how you ended up becoming a doctor.

Scott: I'm from a large family and I'm actually a first-generation physician. No member of my family, even my extended family, had ever been a physician -- in fact, neither of my parents finished college, so I was fortunate that I was gifted with intellect.

Going through school, I always liked science, so I went to Vanderbilt [University] as a molecular biology major and subspecialized in molecular genetics. Back then, we worked for 6 months in order to analyze one protein, but that's the sort of stuff now that is automated and done in about 30 minutes.

I also really liked working with people and helping people, so I went to medical school, which I loved. I chose otolaryngology; it's a great field. One of the great things about otolaryngology is that we get the best of both worlds: I'm a surgeon, but I see patients in the office. We take care of diagnostic challenges and medicinal interventions and we don't operate on everybody, but we do operate.

I see young children who need simple things, like the release of a tongue tie or tympanostomy tubes. I see elderly people who have problems with their hearing, and I see people who are remarkably ill, who have cancer of the head and neck and throat, particularly here in Kentucky. And I see people who are not really sick at all; they just want to breathe better through their nose. So for a small niche specialty, we actually have incredible diversity.

MPT: How did you get involved with the AMA?

Scott: When I was a senior in medical school, I came to the AMA and I witnessed the House of Delegates for the first time. I was amazed that all these physicians from every state, from every specialty, would come together to try to help patients and our profession. And I was hooked. Believe it or not, I've been to 72 consecutive House of Delegates meetings. I caught the fever, I guess you would say.

MPT: You're stepping down as HOD speaker to become president-elect. What are the differences between those two jobs?

Scott: It's interesting that the speaker doesn't really get to speak on the issue -- it's the president who is the spokesperson on the issues. I've always said that one of the key jobs for the speaker is [actually] to listen -- to listen intently as to what is the opinion of the minority, and to respect that opinion, but also, what is the developed opinion of the majority, because ultimately that's how we make policy.

So I'm really excited about this opportunity to try to transition from the development of the policy, to working on the board where we refined the policy, and now [as president-elect and then president] presenting the policy to the public, to the legislators, and to the media.

I have a long history of rhetorical interest. I actually was a high school debater, and speech and debate person, and when I went to Vanderbilt University, I was on their debate team. I just love rhetoric and I love the discourse.

MPT: What issues affecting physicians are you most passionate about?

Scott: I live these issues every day that the AMA is focused on right now. I deal with the fact that physician pay is unacceptably low, and that prior authorization is a ridiculous administrative burden on us. And there's the need for telemedicine. I've got a patient who came to see me from Florida to have a surgical procedure because I've operated on their other family members, and now they're [back] in Florida and [suppose] they have some questions, or maybe a problem. And without telemedicine what are we going to do: tell them to drive 12 hours? Or am I going to send them to a different doctor there who doesn't know the case?

The patient is a young man, 19 years old, who has got three different congenital syndromes that he's dealing with. He is a very complex patient. So I'm going to connect with them by telehealth and see if it's something that I can help with, and if not, at least be more intelligent when I talk to the local doctor.

MPT: The AMA has been trying to push its Recovery Plan for America's Physicians. How is it going?

Scott: Let's talk about what I consider the most important part of it. For years, physicians kind of shied away from discussing physician pay, but you know, I think we need to change that strategy. I'm in an independent private practice; there are six of us. Private-practice physicians in particular, we're on the brink of losing our practice for financial reasons. We have faced 20 years of stagnant Medicare pay, and in inflation-adjusted dollars, that has resulted in a 22% reduction in what physicians are paid in 2021 compared to 2020, and in 2022 and 2023 there were further reductions.

At the same time, particularly in the last year, all of my expenses have increased. Almost on a weekly basis, one of my employees is asking for more money; they need more money to pay the gas bills and food bills. And the fact is that I'm also competing with [places like] UPS and Ford. At our surgery center, we lost one of our RNs because she was able to make more money working as a line person at an automotive plant. That's a problem.

What magnifies the problem is that private payers, years ago, figured this whole thing out, and they have linked their contracts to the Medicare pay rate. So in effect, they save money because they don't give us any kind of an inflationary increase [because Medicare doesn't]. I had a major health insurance company offer us a contract that is based upon 80% of Medicare. And they offered us surgical rates that we pointed out to them were less than the rates they paid us in 2017. This company has 60% of the private-pay market in this city and in this region. Three months ago, we started trying to negotiate with them, and they have stonewalled us ever since ... Their attitude is "take it or leave it." I wish I could tell you that it was just this one company and no one else is like this, but this is standard operating procedure right now.

Our options at this point are to say no to the contract, but that leaves our patients out in the cold. That also financially hurts our practice; we can't walk away from 60% of our business. And our other alternatives are to become employed by the hospital, which is something we've not been wanting to do, or to walk away from our patients, or alternatively tell our patients that they're going have to pay us out-of-network. So we have no good choice here.

That is unfortunately happening across America, and this is why you have one out of five doctors saying that they want to look for a different career or retire in the next 2 years. That's a crisis.

And then [there is] the administrative burden. I spent time on the phone today talking to someone to get a CT scan authorized. And the person I was talking to didn't even know how to say the anatomical phrases that we were theoretically discussing. And my fellow physicians all face the same challenges.

We have had some positive movement with the Recovery Plan. We've had legislation that has been introduced that would potentially give us an inflation adjustment. We've had some movement on telehealth; we've gotten coverage through the end of 2024. We need to get that extended and permanent. We've had some movement on scope of practice in some areas of the country, and we were successful in supporting the Lorna Breen Act to help physicians who are in [a mental health] crisis. We've been successful in helping a number of states develop physician wellness programs.

MPT: Can you talk more about what's happening with prior authorization?

Scott: Two years ago, I testified before the Kentucky legislature about prior authorization. And I would love to tell you that I gave really compelling testimony because I'm such a powerful speaker, but the person who spoke after me was the mother of a young girl, probably about 14, who had a seizure disorder. Her seizures had been controlled with a medication, but the insurance company started requiring prior authorization for the medication and because of a delay in the prior authorization approval, she had seizures. Then they approved the medication, but lo and behold, it was in December. So in January they had to do prior authorization again, and the delay resulted in her having seizures again. Then in March, her employer switched insurance companies and the new insurance company required prior authorization for the same medication, and she had seizures again. She suffered brain damage from these seizures. And the young lady was there sitting in the front row.

That was the testimony that got Kentucky to pass prior authorization rules that say once something is authorized, it's authorized for a full year and it's authorized for the course of treatment, and that once one insurance company authorizes it, it should roll over to the next insurance company. That's the sort of change that we need.

MPT: Is there anything you want to tell us about your personal life?

Scott: I enjoy travel, hiking, and outdoors activities. Most of my free time I really enjoy spending with my family. I have an 8-month-old granddaughter from my son and daughter-in-law, and my daughter is expecting in August; it's another granddaughter so we're excited about that. And our family is [big]; when we get together for gatherings like Thanksgiving, there are more than 40 of us. My mom is 95 years old and still alive, healthy and mentally sharp.

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