Cite as: Provenzano D. President's message: ASRA Pain Medicine advocacy and the development of future physician leaders. ASRA Pain Medicine News 2024;49. https://doi.org/10.52211/asra080124.001.

When I started practicing 18 years ago as an anesthesiologist and chronic pain specialist, healthcare status was very different. At that point during my career, I did not realize the important role that physician advocacy would play in maintaining patient access to care, physician well-being, and practice viability. I was not worried about the impediments of prior authorization and the challenge of scope creep, and I did not think that Medicare reimbursement would continue to decrease. Prior authorization was not required for most pain treatments, and administrative and staff burdens were significantly lower. Although my love for caring for patients has not changed, and my passion for science continues to flourish, the practice of medicine has clearly gotten harder. Jessica Russell (the clinical nurse who has been with me my whole career) and I often reflect on the old days when we would see a patient with a herniated disc with excruciating pain who had not responded to conservative measures and just be able to schedule them for an epidural without spending an extensive amount of time on prior authorization.

So, what has happened in the last 18 years? Private practice physicians have become a rarity. The share of physicians who work in private practice had decreased to 46.7%, a 13% drop between 2012 and 2022 alone.¹ In addition, prior authorization is required for almost all interventions, Medicare reimbursement has significantly declined while office overhead continues to increase, and scope creep continues to gain momentum. Specifically, I do not state these facts to become depressed or a victim but rather to highlight the importance of advocacy. Let's look at some of the changes. There is no doubt that prior authorization is leading to significant clinical challenges and reduced patient access. Specifically, the 2023 AMA Prior Authorization Physician Survey demonstrated that:

• prior authorization increases physician burnout a lot or somewhat for 95% of physicians,
• a serious adverse event for a patient in their care resulted from prior authorization for 24% of physicians,
• prior authorization sometimes causes treatment abandonment; according to 78% of physicians,
• physicians and their staff devote at least 12 hours weekly to prior authorizations,
• 27% of physicians report that prior authorizations are often or always denied, and
• 35% of physicians have staff who only work on prior authorizations.²

Medicare reimbursement continues to decline. Each year, physicians beg for assistance. Specifically, when adjusted for practice cost inflation, Medicare physician payment has declined 29% from 2001 to 2024.³ This is unsustainable. Physician overhead during this time has significantly increased, and unlike other parts of the health system, including hospitals and ambulatory surgical centers, physicians have not seen any increases in funding. The continued cuts in Medicare reimbursement over the last 23 years have reached a tipping point.

So, let's go back and think about that individual that I discussed in the beginning, the person with a herniated disc causing excruciating pain. All you want to do is help that individual. Still, before you can do that, you must go through an extensive prior authorization step that delays care, increases administrative burden, and leads to staff and physician burnout. Furthermore, the Medicare reimbursement for interlaminar lumbar epidural steroid injection with image guidance (CPT 62323) is less than $100. Private insurers often follow Medicare reimbursement. Therefore, it is close to a zero-sum game when you think of all the staff time that goes into prior authorization and your time. This is just one example of why providing care to patients and maintaining economic viability is hard.

Scope creep continues, and patients want physicians to manage their healthcare. Unfortunately, scope creep continues in all aspects of medicine, from physician assistants and nurse practitioners to certified registered nurse anesthetists (CRNAs), pharmacists, and optometrists. A 2023 AMA survey showed:

• 91% of patients think a physician's education is crucial for getting the best care,
• 75% would rather wait longer and pay more to see a physician, and
• 95% want a physician to be involved in their diagnosis and treatment.⁴

There is no doubt that optometrists, CRNAs, nurse practitioners, and physician assistants are important to the healthcare system and a critical part of the care team. However, it cannot be denied that physicians have much higher education and clinical training levels. The table below compares the education and training requirements of physicians and nurse practitioners, one of the largest groups of non-physician providers, and physician assistants. You will also see the comparison of anesthesiologists to CRNAs.

Physicians have significantly more education and training than CRNAs, physician assistants, and nurse practitioners, enabling them to provide more comprehensive and complete patient care. While CRNAs, physician assistants, and nurse practitioners can play a valuable role in the healthcare team, they should not practice independently without physician supervision or oversight.

Solutions and Efforts

ASRA Pain Medicine attended the AMA Annual House of Delegates (HOD) Meeting in Chicago from June 7-12. During this time, ASRA Pain Medicine representatives, including me (Delegate representative), Lee Tian, MD (Alternate Delegate representative), and Edgar Remotti, MD (Resident Fellow Section representative) were actively involved and contributed to the AMA's efforts to enhance health care. As I have mentioned in my previous newsletters, it is very hard for individual medical groups to address systemic issues that affect the healthcare system. Therefore, it is essential that ASRA Pain Medicine participate in large physician group advocacy efforts. Since we joined the AMA in 2022, ASRA Pain Medicine has been at the table.

This year specifically, ASRA Pain Medicine took part in the HOD meeting, Pain and Palliative Medicine Specialty Society Council meeting, Anesthesia Section Council meeting, Specialty and Service Society meeting, Federation CEO meeting, Mobility Caucus meeting, Residents And Fellows Section meeting, and Scope of Practice Summit. Before the meeting, the Practice Management Committee, led by Drs. Kevin Vorenkamp and Sandra Kopp, examined the proposed resolutions to provide feedback to help prepare the ASRA Pain Medicine representatives. The full list of the ASRA Pain Medicine supported reports and resolutions can be viewed here. Moreover, we witnessed Dr. Jesse Ehrenfeld pass his presidency to Dr. Bruce Scott. Dr. Jesse Ehrenfeld was the first anesthesiologist to lead the AMA. This was a historic event and achievement for the field of anesthesiology. We are grateful for Dr. Ehrenfeld's efforts over the last 12 months in improving the practice of medicine.

The AMA, with all its physician partners, is launching significant efforts to improve all aspects of healthcare. Below are some key areas of the AMA’s advocacy efforts and solutions from its recently updated progress report.

Fixing prior authorizations

• Accomplished a final rule requiring government-regulated health plans to reduce timeframes for prior authorization decisions
• Facilitated an agreement with United Healthcare and Cigna, reducing the volume of prior authorization requirements

Reducing physician burnout

• Worked closely with partners to secure change in medical boards and health systems to remove application questions that may deter physicians from seeking care
• Advocated for new laws and policies that protect physicians in seeking care for burnout

Reforming Medicare payment

• Secured introduction of H.R. 2474, with bipartisan cosponsors, to apply an automatic inflation update to Medicare physician payments by tying the Medicare physician fee schedule to the Medicare Economic Index
• Attained the introduction of H.R. 6371 to revise budget neutrality policies to mitigate inappropriate payment schedule conversion factor cuts

Advocating for solutions to cybersecurity issues

• Worked to find solutions to the Change Healthcare cyberattack to provide practices an avenue to maintain financial stability while providing appropriate care
• Assessed the critical impact of the Change Healthcare cyberattack on physician practices and used the information to push for accommodations from all stakeholders

Promoting physician-led care

• Assisted in defeating legislation that would have allowed for inappropriate scope expansion across the country
• Continues to work to ensure veterans are provided the physician-led care they deserve

Pursuing solutions to the physician workforce crisis

• Encouraging Congress to add additional graduate medical education slots and funding to allow more physicians to be trained

Fighting government interference in evidence-based medicine

• Working with policymakers to secure access to the full spectrum of reproductive health care⁵

You can check out the full list of the AMA's 2024 advocacy efforts here.

In March of this year, ASRA Pain Medicine took the next step to increase its advocacy by launching the Pain Medicine Coalition (PMC) in conjunction with the American Society of Anesthesiologists (ASA). The PMC will advocate for responsible pain care for all patients and the physicians who support them. ASRA Pain Medicine and ASA are working closely to establish priorities for the coalition so that there is clear direction and focus on its initiatives. As the coalition grows, its members, reach, and influence will be more expansive, and the ability to create change will be evident.

The upcoming 23^rd Annual Pain Medicine Meeting will occur November 21-23, 2024, in Las Vegas, Nevada, at Caesars Palace. The theme for this year's meeting is "LET'S GO! Advancing Advocacy and Access." The meeting chair, Dr. Christy Hunt, has developed a program that will include practice management strategies for prior authorization, self-pay plans, interpretation of local coverage determinations, and updated documentation requirements. Dr. Hunt and the program committee have done a fantastic job incorporating practical tips by ending each session with billing, coding, and practice management pearls. Attendees will leave this meeting with the tools they need to improve their practice and provide the best care to their patients.

The healthcare system is currently sick and needs revitalization. I am optimistic that by working with other physician groups, including the AMA and the Pain Medicine Coalition, ASRA Pain Medicine can restore the system to a healthy state for our patients and members. I am even more convinced when I see young physicians like Drs. Lee Tian and Dr. Edgar Remotti involved in the fight.

References

1. American Medical Association. Physician practice benchmark survey. https://www.ama-assn.org/about/research/physician-practice-benchmark-survey. Updated May 16, 2024. Accessed June 23, 2024.
2. American Medical Association. AMA survey indicates prior authorization wreaks havoc on patient care. https://www.ama-assn.org/press-center/press-releases/ama-survey-indicates-prior-authorization-wreaks-havoc-patient-care. Published June 18, 2024. Accessed June 23, 2024.
3. American Medical Association. Medicare physician pay has plummeted since 2001. Find out why. https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-has-plummeted-2001-find-out-why. Published June 17, 2024. Accessed June 23, 2024.
4. American Medical Association. Advocacy in action: Fighting scope creep. https://www.ama-assn.org/practice-management/scope-practice/advocacy-action-fighting-scope-creep. Updated June 5, 2024. Accessed June 23, 2024.
5. American Medical Association. Scope of practice: Education matters. https://www.ama-assn.org/practice-management/scope-practice/scope-practice-education-matters#:~:text=Naturopath-,Why%20education%20matters,a%20complication%20or%20medical%20emergency. Updated August 31, 2023. Accessed June 23, 2024.
6. American Medical Association. AMA advocacy efforts. https://www.ama-assn.org/health-care-advocacy/access-care/ama-advocacy-efforts. Updated June 4, 2024. Accessed June 23, 2024.