Adam J. Bruggeman, MD, MHA, Explains the Changing Landscape of Prior-Authorization Reform

AAOS Now Editor-in-Chief Robert M. Orfaly, MD, MBA, FAAOS, sat down with Adam J. Bruggeman, MD, MHA, FAAOS, FAOA, chair of the AAOS Advocacy Council and orthopaedic spine surgeon at Texas Spine Care Center in San Antonio, to discuss how the battle over prior authorization is evolving and gaining momentum through new partnerships and approaches. For more context on current initiatives related to prior-authorization reform, read “Relieving Administrative Burden: How Surgeons, Washington, and Industry Partners Are Working to Reform Prior Authorization.”

Dr. Orfaly: Please give us an update on what the latest advocacy initiatives are for the Advocacy Council.
Dr. Bruggeman: From a prior-authorization standpoint, we’ve had a lot of articles lately written in the popular press. ProPublica, STAT, and other groups are looking at how much [prior authorization] impacts our patients. We talk about it all the time, but it’s very interesting to hear the real stories of different specialties other than orthopaedics who are dealing with getting medications or getting oncology treatments. Those have really shined a new light on prior authorization. That has continued to light a fire underneath people in Washington, D.C., [showing] that we need to do something. We can’t keep letting this happen.

At the end of the day, the prior-authorization reform that’s occurring couldn’t occur through the normal legislative way, so we had to go through the White House and through the Centers for Medicare & Medicaid Services. Now finally, we have another bill, but that’s just going to affect a small component of prior authorization. We need to think about the next steps. What is our next fight? We certainly have the “gold card” ideas [where commonly approved procedures gain “gold card” status and are exempt from needing prior authorization]. Rep. Michael Burgess, MD (R-Texas), put the “gold card” bill out there. We’ll need a new champion [in 2025] because he stepped down from being a member of Congress.

But what we’re really seeing is a new ally in this fight—hospitals. As we know, many of our fellow surgeons have become employed by hospitals over time, and in addition, we’re doing a lot of cases at hospitals. We’re seeing a new form of prior authorization, which is post-procedure lookbacks and clawbacks, where [insurance companies] are taking money away from the hospital and saying, “Oh, we aren’t quite sure we agree with our original determination, and we want to claw our money back.” Or they’re asking the hospitals for an intense amount of information that lives in our physician offices but doesn’t necessarily live in the electronic records of the hospital. So it’s going to be very interesting as this evolves, as we see more stakeholders start to jump in. At one point, it was just impacting the doctors, but now from a hospital standpoint, they employ the doctors, and they’re being asked for clawbacks. Maybe we need to bring some other people into this and begin having forward-thinking conversations with insurance companies to identify ways that we can work together to achieve mutual goals of ensuring quality patient care that matches the things that we hold to be appropriate as AAOS. But also, understanding that the insurance companies want to have a check and balance in place, how do we do that effectively?

You and the AAOS Office of Government Relations are actually having conversations with the insurance companies, or at least trying to initiate that, in order to have some common ground reached.
UnitedHealthcare just came out with their own unique “gold card” issue. We were unaware of that process; we knew that something might be happening. But unfortunately for orthopaedics, it really didn’t involve total knees, total hips, rotator cuffs, knee scopes, spine surgery, foot and ankle surgery. We didn’t get the big surgeries that we would have wanted to see being included in that “gold card.” Instead, it was mostly related to imaging that we order. It would be nice to be able to have those conversations and be at the table. Going forward, our goal is to at least have the conversations, keep an open dialogue, know when they are trying to enact change, and ensure that before the change is enacted, we’ve at least had an opportunity to provide some input on behalf of our patients and on behalf of our fellowship.

There’s a pitch for every Fellow, if you have any sway, during any conversations with your hospital, with your system, to advocate for the same points that the AAOS Advocacy Council is working on.
Exactly right. We are going to need as many people in the boat with us as possible. And as we all know, the hospital association has a large voice here in D.C. but also has a large voice commercially with insurance carriers. And so getting these larger hospitals that are also being impacted by these prior-authorization rules, getting them in with us and having the same conversations and speaking the same language and asking for the same things are going to really help us fight the prior-authorization battle.

Robert M. Orfaly, MD, MBA, FAAOS, is a professor in the Department of Orthopaedics and Rehabilitation at Oregon Health and Science University. He is also the editor-in-chief of AAOS Now and chair of the AAOS Now Editorial Board.