Dr. Oz (00:01):
How many of you have had a pre-authorization issue in your family? Show of hands. It's about reflective of the national average. 85% of Americans say they've had pre-auth effect them in ways they wish it hadn't. It's the number one complaint, not only from patients, but providers. Doctors, like myself, are continually struggling with this issue.
(00:21)
We have spoken frequently about how Health and Human Services, and the agency in charge of Medicare, Medicaid, and the insurance plan, CMS, is open for business. We like to have private solutions when they're feasible, and today you're going to hear about one of the biggest ones possible, one that will address this issue of prior authorization.
(00:40)
In 2023, the last year for which we have strong data, the Medicare Advantage Program, which administers care to… total Medicare is about 68 million people, half of that is Medicare Advantage, so it's 32 million people, a lot of folks, partially or fully denied 3.2 million claims, initial requests for prior authorization. It's a lot of people, not just numbers, those are individuals who often in the most vulnerable time in their lives needed something done and it was denied for one reason or another.
(01:13)
Each week, on average, a physician handles about 40 of these pre-authorization issues and requests, and spends about 12 hours a week on paperwork in general, often aimed at addressing the prior authorization issue. It frustrates doctors. It sometimes results in care that is significantly delayed. It erodes public trust in the healthcare system. It's something that we can't tolerate in this administration.
(01:36)
And under the leadership of Secretary Kennedy, this agency has not wanted and has expressed its frustration. And for good reason, because of that and because of folks who actually maybe entered into the industry because they had the right motivations at heart, we have just concluded a roundtable, one of the most impressive that I've been involved in, with the CEOs who represent about 75% of all covered lives in America.
(02:02)
These folks represent the insurance companies that cover three-quarters of the American people, and it covers them across Medicare Advantage, across Medicaid, across commercial insurance, about 260 million people in total covered by these plans. And there were more people being added while we were in the meeting. That's how much interest there is from industry in dealing with the problem that they don't like to have in their bailiwick either. These executives explain why they are signing this pre-authorization pledge to restore common sense to the process.
(02:32)
Now, we've spoken to these folks, and others in industry, about the desire for them to maybe adopt a different strategy. One that actually is discussed in the Bible, and it says, "The meek shall inherit the earth." And I always grew up thinking meek meant weak, but that's not what meek means. Meek means you have a sharp sword, a sword that could do real damage to people around you, but you decide electively to sheath that sword and put it away for a while so you can do good. So you can do important things where once in a while we have to get together, even if we're competitors, and agree. And that's what these insurance companies and hospital systems have done. They've agreed to sheath their swords to be meek for a while to come up with a better solution to a problem that plagues us all.
(03:12)
And this transition that's now happening, this teaching that's sort of spreading, is beginning to catch fire in part because this administration has pushed so hard on these issues. We're hearing very innovative ideas. For example, could we allow some physicians to be gold card physicians, because they're so good at making the right care for the right patient that maybe they don't have to go through a pre-authorization. There's some systems that don't even do pre-authorizations because they have already evolved into having ways of giving feedback to doctors. So they learn when they're ordering tests and medications that aren't the right solution to a particular problem, so they don't repeat those errors. At its best, that's what pre-authorization sought to do, but that's not what it's doing anymore. So for that reason, the pledge.
(03:56)
And some of the highlights are in this chart to my right, so you can at least follow along, but I'll mention that the top three issues that we're focused on. The first, is timely access for patients. This is a critical issue, because imagine you're at a doctor's office and you've got a bad diagnosis and there's a procedure or test or a treatment that you think is right for you, and you find out that you can't start that treatment for sometimes weeks, even longer. It's more frustrating than anything else in the process because at least that's something you do control. You don't control much else when you're in a physician's office with that kind of a crisis. And yet it's withheld. And these approvals, with this new pledge, will be streamlined. It will happen very quickly. Necessary care will be delivered when it's needed in the right way. So you'll get both quality and you'll get timing which goes along with that quality. And you won't get that treatment after all the paperwork clears, you'll just get it because there won't be paperwork, we'll be streamlining it. Patients should not be waiting because bureaucratic hurdles are blocking their critical treatment.
(04:55)
Second big issue, is to make sure that we are saving the system with efficiency. I bring that up because one of the biggest challenges we have within CMS, which is again, Medicare, Medicaid, the exchanges, is that it's an inefficient process by which we do things, by which we give feedback, by which we send bills and collect. The red tape creates massive problems. We want less red tape, and if we do that, we can cut tens of billions of dollars of administrative waste. It's a lot of money that we throw at solutions that don't work for us, 'cause we haven't built a digital infrastructure. That's being addressed, with less red tape, that means more resources for patients, which is part of the reason these major companies got together, working together with Health and Human Services Agency to try to take a shot at the pre-auth process.
(05:42)
We'll standardize, we'll harmonize, we'll get folks talking together. And the pre-authorization process, if it's done correctly, for ongoing procedures, for medications and the like, will create a seamless relationship between patients and providers, which is the whole goal in the first place, to allow them, to free them, to get across the finish line with their treatment plans. But to do it together with the insurance entities, the folks that are responsible for these different plans.
(06:07)
And thirdly, transparency. And transparency comes with accountability. If you now know what's going on, you now have the responsibility of dealing with it. We have common data standards, they're going to be adopted, and public dashboards are going to reveal to you and to patients what's going on. So we'll be able to audit if this is really happening. Because although we're hopeful, this is hard to do. And folks sometimes change their mind, we don't want that to happen. So we're going to trust, but verify, by having this transparency and accountability. All the stakeholders, the payers, the providers, the patients, are going to see real world performance. And by having that, they'll be able to assess whether this is clearly and consistently accomplished.
(06:46)
Now, the pledge is not a mandate. This is not a bill or rule, this is not legislated. This is an opportunity for industry to show itself, participation is voluntary. But by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it's a good start. And the response has been overwhelming, gratifyingly so. The effort took place with the government as a sponsor, as a steward, as a cheerleader. It was led by wonderful people who realize that we had an opportunity to do good and that government, you don't have to always do it yourself, you can use the power to convene, to pull together powerful interests.
(07:22)
We have discussed extensively with individual physicians, this idea. We've talked about it with health systems, with associations, with congressional partners. You'll hear from some of them in a moment. CMS is going to publish a full list of participating plans later this summer with some details of how it's going to roll out. And the initial commitments, like for example, code reductions, the number of procedures that would have to be subjugated to pre-authorization or similar limitations, the continuity of care protections to make sure that you don't lose coverage when you switch between plans, it's going to go live by January of '26. It's a fast timeline, but in seven months, we'll be able to give to the American people something they've been asking for, something that's been in the news recently because of the difficulty of obtaining it, which is the freedom from prior authorization when used incorrectly.
(08:09)
So what's the blueprint for broader reform? Because we see this as the first of a much larger opportunity. This is getting everyone together on a pain point, a thorn in everyone's side, a pebble in our shoes. But the real opportunity is use this as the first and very important step in building a larger blueprint. Because it's not just about prior authorization, it's a template for administrative simplification, to take the paperwork out of the process and put patients over paperwork.
(08:35)
There's going to be a single fire-based electronic workflow. Fire is a fast healthcare interoperability resource, so it's a standardized way for information exchange across systems. We'll have real time decision-making for most electronic requests by 2027. We're going to have to work with providers, with doctors, many of whom, maybe half potentially, aren't using these kinds of technologies routinely in their office practice when they interact with insurers. We want that to change, so we don't have a slowing down of the process. There shouldn't be paper, there shouldn't be faxes, there shouldn't be letters being sent. They should all be done digitally and automatically. And 90-day continuity should exist for authorizations when patients switch insurers, so you never fall through the cracks. Again, another pain point that many patient groups are bringing to us.
(09:21)
The future is a system where carriers compete on value and outcomes. They compete on value and outcomes, they do not compete on issues like confusing portals and who can obfuscate the most and delay the process the most. That's not how they want to win, and that's not how they're going to win.
(09:38)
We want to recognize the insurers who've done this and they have stepped up. They're sharing data in ways that we are very honored by. They're willing to be meek in the process, in ways that we had not even initially anticipated. They're accepting performance targets. They are offering commitments that go just beyond the profits that are involved in this process. Although we're hopeful that we'll actually save some money through this process, because we won't be wasting the amount of money that is often spent unnecessarily when documents are sent back and forth, taking up precious time without changing the overall [inaudible 00:10:13] results. This shows what's possible when policymakers get together with payers and they can join forces to make the care faster, simpler, and more affordable for the American people.
(10:22)
So what comes next? Well, today's the beginning, and it really is just that. As this process rolls out, we're going to be seeing exactly how the engineering occurs. CMS is engaging with providers to find out how they can refine documentation procedures, because that's often where the entire process gets stuck. The records never get out of the doctor's office in a timely fashion.
(10:44)
We have patient advocates identifying low-value codes. There's some things we should not be pre-authorizing anymore, and we should stop that. And the insurance industry agrees with that, by the way. The health IT innovators who are out there who want to help, there's an opportunity for them to extend real-time prior authorizations. So literally as the decision is being made that you as a patient need a test or a medication, the decision is at the same time made by the insurance company that it's okay. And this is going to allow us to next proceed into looking at ideas with pharmacy and behavioral health. So those opportunities and pre-authorization processes are accelerated.
(11:19)
In closing, I'm going to applaud these insurance companies for taking a very thoughtful, brave first step. That stated, I know that we're going to have to keep watching what everyone's doing carefully. I want to be clear about that reality. If the insurance industry cannot address the needs of pre-authorization by themselves, there are government opportunities to get involved. They might not be as nimble, but they will be used if we're forced to use them.
(11:42)
We've, I think, convinced all the folks to come to the table, and I'm optimistic with that that we're going to be successful. And there's a lot to be said about this, but I want to bring some folks in who have been very actively engaged in this process. And I'm going to start with a gentleman, who's known to many of you,
Dr. Oz (12:00):
… because he's been on television in front of tens of millions of people playing an active role as a doctor, although he's not a doctor in real life, but he does have a health problem and is chronic, so it's going to force him to deal with the pre-authorization system. And this is an exact kind of situation where you don't want pre-auth hindering and limiting your ability to get the care you need. Some of you know him as Dr. McSteamy from Grey's Anatomy, but Secretary Kennedy and I call him friend, Eric Dane. Eric, come on up. And I'll have Eric share his diagnosis when he comes up. He's been very public about it, which is a brave thing to do, but I also appreciate you making time in your schedule to address America about pre-authorization.
Eric Dane (12:49):
Thank you.
Dr. Oz (12:49):
Bless you.
Eric Dane (12:51):
That's my [inaudible 00:12:52].
Dr. Oz (12:53):
I was told not to take his talking points and I did.
Eric Dane (12:56):
Don't take my words. Thank you, Mr. Administrator Oz. I'm Eric Dane. Some of you may know me from TV shows such as Grey's Anatomy, which I play a doctor. But I am here, I'm here today to speak briefly as a patient battling ALS, also known as Lou Gehrig's Disease. When that diagnosis hits and you find out that you're sick, your life becomes filled with great uncertainty. And the worst thing that we can do is add even more uncertainty for patients and their loved ones with unnecessary prior authorization. Anything we can do to give patients more certainty with fewer delays is a worthwhile endeavor. I've been fortunate and have the means to access great care. I'm lucky. Not everyone is in the same position. I am acutely aware of that. I applaud the insurance industry coming together with officials from CMS and HHS to take these steps in the right direction. Today is about all those who need more certainty, faster answers, and more hope for recovery. Thank you.
Dr. Oz (14:27):
Thank you, Eric. You can't capture the pain of the pre-authorization process without hearing from patients, so I appreciate Eric making the time. Physicians live through this continually, and I have two physicians who've volunteered to come over from Capitol Hill despite all the crazy busyness over there and spend some time with us. Senator Marshall is a good friend. We spent a lot of time brainstorming ways to improve healthcare in America. And pre-authorization, if you get two doctors together, always comes up. Senator Marshall.
Roger Marshall (14:53):
Thank you so much. Well, good afternoon, everybody. I want to say a special thanks to Secretary Kennedy and CMS Administrator Dr. Oz, and especially President Trump for inviting me to participate in today's event to address the number one bureaucratic nightmare facing doctors and patients, prior authorization. Now, long before I ran for Congress, I practiced OB-GYN for some 25 years and I vividly remember a patient I once had scheduled for an infertility surgery. She'd taken time off work and arranged help at home only to be told the morning of her procedure that her insurance company had added another step to the prior authorization process, abruptly canceling her surgery. Now, whether you need a hip replacement or a heart catheterization, many patients feel their critical care has been delayed by an opaque and burdensome prior authorization process. It's something I hear about all the time back home.
(15:55)
Moreover, physicians and nurses complain the process has become increasingly onerous because of constantly changing requirements, often demanding more time to navigate the red tape than to complete the pre-surgery medical workup. Today, by having all the players in the room, we hope to see a common-sense solution to streamline and improve our healthcare system. We must prioritize patient's health over corporate profits and arbitrary cost-cutting measures. For nearly my entire time in Congress, I fought to reform the prior authorization process in Medicare Advantage. Today's event moves us closer to that goal, ensuring patients receive timely life-saving and health restoring care. Again, I just look forward to working with Secretary Kennedy, Administrator Oz, and insurers together to overhaul this process. I'm going to continue to champion this fight in Congress and support their efforts. And again, I'm just proud to stand alongside President Trump's A-team as we work to make healthcare more patient and provider friendly for doctors, nurses, and patients alike. Next, I'm just proud to introduce one of my very good friends, a fellow physician, a urologist, still practicing medicine, a congressman from the great state of North Carolina, Dr. Greg Murphy. Greg.
Greg Murphy (17:09):
Appreciate it very much. Thank you, Secretary Kennedy, and thank you, Dr. Oz. How did we end up here? I think that's a real question. I can say now after 32 years in clinical practice, which I still see patients, how did we get here? I think that's really critical. I think we all know that the maternal-fetal bond is probably the strongest human relation there is. I think the second one is the doctor-patient relationship. We saw a lot of that tinkered with during the pandemic. But I still see patients because I love it. I think my patients appreciate it, but it also helps me on a daily basis be cognizant and be present with my colleagues in Congress to talk about issues that are happening in medicine today. Just like Dr. Marshall, I have had innumerable episodes where patients call back crying or patients call back upset that their insurance company would not allow things, would not allow a treatment plan that I as their trusted physician have recommended.
(18:10)
How did that happen? How did we get to that spot? Because guys, that is basically putting somebody between the doctor and the patient, an opaque person in a cubicle which has a list of things that they're allowing and not allowing. How did we get here? We got here with two or three different ways. One is I'm always happy to put the blame where it is. I do think we have some physicians that overorder tests. I do. I have younger partners and I say to them, "Why are you doing that? Is it going to change patient care? Just because you want to know is not an answer." So there is some blame, and I'm happy to point this out on the physician community for overordering things. So I think we have to get, in part of our calculus, better taught in medical school and in residencies, why are you doing this? Why are we doing this?
(18:58)
But that's not where I'm going to put the major blame. Sadly enough, we have people that take a good system, they're honored to be able to provide insurance coverage for all of America for patients. But sadly enough, maybe in some boardrooms or in some other rooms, we've had people to say, "How can we game the system? How can we get more money rather than deliver the money to the people who provide the care?" I think these are great. I would add one. I don't know how many times I've had to stop my clinic or stop in the operating room and talk to another person about denial of care. I need to be able to speak to a peer, not a radiologist, not somebody who is a pediatrician, not someone who does not know my field, but a peer-to-peer to be able to say, "This is what's going on with the patient." And then have the insurance company doctor on the other side should be knowledgeable about what I'm talking about and me not to have to explain them.
(19:50)
So I urge my insurance companies really to offer that up and put one thing forward. This is a great day. It has been years in coming, and it is a day too long in coming, but I'm glad to hear that insurance companies have now understood what they've been doing is not right and that they're coming to the table to try to fix some of those errors. But I will say this, being a surgeon, I'm a skeptic. The proof is going to be in the pudding. Are they really going to step up and do things or are they doing something to placate an audience? We're going to hold them to the fire continually to make sure they're doing what they're saying they're going to do and provide and get out of the room, get out of the space between the doctor and the patient and let the doctor deliver the good care that they know how to do. Thank you very much. Thank you, Secretary Kennedy. Thank you very much.
Dr. Oz (20:40):
I've known Secretary Kennedy for many years and meet a lot of people in life, and I don't think I know someone who's more righteous, who feels so wrong when he thinks things aren't being done correctly. So early on, he raised the issue of pre-authorization and why was it that it was happening at all? And there are some reasons why pre-authorization exists, but he kept pushing and pushing and with the team got everyone focused as someone who has a power to convene does so well. And I wanted Secretary Kennedy to spend a few moments describing his perspectives on pre-authorization and then perhaps we can take some questions. Secretary Kennedy.
Robert F. Kennedy Jr. (21:19):
Thank you, Dr. Oz. During the transition last January, one of the people I was bringing on as a special government advisor was a long-term friend of mine called Jake Levine, and I asked Jake, can you give me an agenda, the most important things that we can do very quickly as soon as we get in there? And Jake called a professor at Harvard named David Cutler, a famous economist who spent an entire career studying the healthcare system and advising reforms. And he posed that question to Dr. Cutler. He said, "What is the single most important thing that we could do to improve the patient experience in this country? How we could do very, very quickly without regulations and without legislation?" And Dr. Cutler immediately said to him, "You can convene the insurance companies and get them to voluntarily agree to end the scourge of pre-authorization. And very early on in the administration, we brought in Chris Klomp. And Chris Klomp, I'm going to ask Jake and Chris Klomp to come up and join me.
(22:41)
Chris Klomp was a very, very, uber successful health entrepreneur from Silicon Valley who specialized in healthcare technology. And in building his company, he had met virtually all of the big insurance CEOs and hospital CEOs in this country. And he spent the last several months calling them each up one by one and getting them to agree to this program. And it was an extraordinary effort. I'm so happy for his leadership, for Jake's leadership on this issue. The two of them have been working hand-in-hand to make this extraordinary day happen. And it's so important for our country because this has been one of the worst things. As Dr. Oz pointed out, 85% of Americans say that they have had delays in healthcare because of prior authorization, and the doctors hated doctor's report that it cost them 12 to 15 hours a week filling out forms. Some nurses are spending over half their time dealing with the administrative burden of this, and healthcare
Robert F. Kennedy Jr. (24:00):
Healthcare is often delayed to Americans. The cost of administration is enormous to our healthcare system, and we're going to be able to eliminate a lot of those costs by what we're doing today. I just want to read you an experience of a very close friend of mine who's a physician, had with this, one of his many experiences, bad experiences with pre-authorization. This is all too common in our country.
(24:37)
A patient from New Jersey suffering from severe heart failure was transferred to New York Presbyterian Hospital for a life-saving transplant by my friend, the doctor, to survive until a donor heart became available. The patient urgently needed a mechanical heart pump, a device essential to sustain their life during the wait. The insurance company had approved the heart transplant, but then denied authorization for the mechanical heart pump, deeming it unnecessary.
(25:09)
The decision created a perplexing contradiction. The patient was cleared for a transplant and not for the critical device needed to keep him alive until the transplant could happen. With the patient in the operating room and his life at stake, the medical team was faced with a profound ethical challenge. Should they adhere to the insurance company's denial, which would likely lead to the patient's death? Or take action to save the patient's life, knowing it could result in legal or professional consequences?
(25:41)
The medical team chose to prioritize the patient's survival. Implanting the mechanical heart pump, this decision allowed the patient to live long enough to receive a successful heart [inaudible 00:25:52]. My friend, the doctor, was then sued by the insurance company. Ultimately, that lawsuit was dropped, but there are many situations in this country where that ethical decision for one reason or another would not have been made and people lose their lives because of prior authorization.
(26:14)
In the past, the insurance industry has made commitments to prior authorization, but they have not kept them. In this case, we think it's very, very different because one, a number of patients covered by this is unprecedented. As Dr. Oz said, 257 million patients are covered by the group that we met with this morning. While we were in that meeting, another company joined the group. We expect we're going to have rolling enrollments, so we expect many other companies to also join.
(26:52)
The other difference is we have standards this time. We have deliverables, we have specificity on those deliverables. We have metrics and we have deadlines, and we have oversight. I'm very grateful to the insurance company for stepping up and the hospital systems for stepping up. We're all very, very grateful to President Trump for his leadership in giving us the impetus to make this happen.
(27:27)
This has been something that we have been struggling with in this country for decades. Two decades, the presidents have promised to do this and none of them have succeeded. Congressman Murphy has been working on this issue for 35 years, and it's a priority for him and it's been a priority for many people in Congress. Can I ask Congressman Murphy and Senator Marshall to come up as well?
(27:54)
So today, because of President Trump's leadership, we are agreeing to this momentous and monumental accomplishment, achievement. We hope to see the dividends of this success story immediately materialize as a better experience for millions, hundreds of millions literally of American patients. I want to thank all of you for being here and we're happy to take questions.
Speaker 1 (28:32):
Dr. Oz, [inaudible 00:28:32] conducting those audits of the insurers itself. If so, how? What exactly will the audit [inaudible 00:28:46] dashboard be available?
Dr. Oz (28:46):
So the dashboard is something you should be able to audit as well. It would hopefully be public so people would have transparency into the process. The insurance companies have all sort of felt the same, at least sung from the same hymnal, that the major limiting factor are doctor's offices' abilities to provide digital data to them.
(29:02)
So we also want to keep doctors accountable. What percentage of doctors are actually able to send over a document in a timely fashion so this claim can be adjudicated instantaneously. Chris, you want to take the question about the platform it's going to be on?
Chris Klomp (29:15):
Yep. Chris Klomp, Director of Medicare for CMS. Industry has pledged to provide metrics along several key dimensions, including numbers of percentages of code reductions requiring pro authorization, as well as adherence to defined standards around timeliness and transparency of that process. As well as adoption of electronic prior authorization standards that are being rolled out as part of the regular rulemaking process by CMS, both for medical procedures and for pharmaceutical procedures. Those should be available on the AHIP website. We intend to publish those as well ourselves at CMS.
Speaker 2 (29:54):
Go ahead.
Phil (29:54):
Phil [inaudible 00:29:58]. Dr. Oz, you mentioned, you'd like to see a lot of services no longer subject to prior auth. Can you give us a list of what your top five would be? Has the industry agreed to any of these yet?
Dr. Oz (30:09):
The industry wants to reduce the number of procedures. Let me give you some numbers and I'll ask Chris to brainstorm on five ones that you think are particularly egregious. If you want. There are about 15,000 procedures generally that could be candidates for pre-auth, about 15,000 procedures generally. There's about 6,000 that get pre-auth, but they're not the same ones for every insurance company.
(30:29)
So there's probably two or 3000 really core events that you probably want to have pre-authorization for, also for the betterment of patients to make sure these procedures are done correctly. Knee arthroplasty or arthroscopy as an example. So is the right patient getting at the right time by the right physician for the right indication?
(30:47)
So if the insurance companies can narrow down the scope of the pre-authorization requirements to really address the ones that are most likely to be abused, it'll make the whole process more seamless. They've argued actually that similar to what e-prescribed did, you create a set of standards and all of a sudden you can do electronic prescriptions. They think once they get this standardization process for pre-authorization, it would open the door for many other types of administrative burden reduction as well. Chris, five ideas you might have.
Chris Klomp (31:18):
I'll give you a few. Colonoscopy, cataract surgery, two-day stay, vaginal delivery, things that are pretty common that are less likely to be abused. I think the bigger point and what we're more focused on is the process and the principles by which appropriate care is determined. Let me give you an example.
(31:34)
Take a given episode of care that might require two different imaging studies as well as three different diagnostic lab studies all in sequence. Status quo today for many insurers is that each one of those separate components will individually be pre-authorized. That's illogical. We know what the episode of care is.
(31:53)
That episode of care arguably wouldn't require and shouldn't require pre-authorization at all. If it does, it should be done once, it should be done quickly, it should be done almost invisibly to the patient. Then the patient, the provider should be left to go about delivering care and the business of healing.
Robert F. Kennedy Jr. (32:10):
I'll add one other thing, is that there's six commitments that the insurers have made to us during our meeting today. One of those is interoperability. This is very critical because right now each insurer has different rules for compliance. Some of them demand correspondence by fax. Some of them have their own portals on the internet where you upload the data and upload the patient's records. Other ones require a conversation by telephone.
(32:44)
So every time a doctor has to or a doctor's office has to go through this process, they're facing this kind of Byzantine collection of procedures that they may not know for that particular insurance company. If they do it wrong, if they correspond by facts, they get denied. So these companies have now agreed to unify their protocols so that all of them will communicate in the same way and to standardize the process. That's going to dramatically change the patient experience.
Roger Marshall (33:24):
Secretary Kennedy, if I could just give you one example. Chris mentioned vaginal deliveries. Yes, we have to prior authorize vaginal deliveries and whether the insurance company said we could deliver the baby or not, we went ahead. To your point, every other week, one of my nurses would spend the better part of the day going through authorization processes for the deliveries upcoming in the next couple of months.
(33:46)
It becomes this ping pong delay game and just the hassle factor. So whether my nurse taking a blood pressure on one more patient that's sitting there with swelling and abdominal pain, trying to figure out if they have preeclampsia or not, and says she's in the side room working on preauthorization. So this is, as Dr. Murphy mentioned, it's an everyday hassle factor for us.
Greg Murphy (34:09):
I'll just say one thing. I think one thing that we know today is a different age. Artificial intelligence should help this tremendously. Tremendously. It should take out a lot of the variances that happen between doctors, hospitals, regions of the country, et cetera. Remember, artificial intelligence only is as good as what you put into it.
(34:27)
So if your artificial intelligence, as some has already had happened, puts into a key to deny on basic tenants, then the denial rate's going to be the same. So I think this is another proof in the pudding that we're going to have to see, are these people actually putting into the AI things that are reasonable, things that are medically necessary so that what's spit out is reasonable for the patient, most important for the patient, and reasonable for those who provide the care.
Speaker 2 (34:54):
Go ahead. In the white.
Rachel Cohrs Zhang (34:57):
Hi there, Rachel Cohrs Zhang with Bloomberg. It seems like you're leaving the door open to regulating here. I was wondering if you could offer any color about what would lead you to believe that it would be necessary to regulate? At what point do you decide enough is enough, it's time to move forward with regulation here?
Dr. Oz (35:14):
As high as the numbers that we quoted for the insurance executives that we just met with upstairs, 257 million Americans. That's not all the Americans. So we still have about 25% of Americans whose insurance companies are not represented in the meeting today. During the meeting, another one joined, but they're not all there. Until they're all there, we're going to keep pushing and shoving.
(35:35)
Even the people who are already in the room agree that there's a possibility you may have to help nudge people, hurt people, so you'll make the right decisions in a timely fashion. What Secretary Kennedy outlined is really critical. If we address the interoperability challenges of the industry, it actually helps them do what they probably want to do already. The beautiful thing about this pre-authorization process is in discussions with these
Dr. Oz (36:00):
… the insurance executives in private, they all sort of want to do it. They just couldn't do it that easily. So using the ability of government, and under President Trump's leadership and Secretary Kennedy's passionate desire to address this, we made it clear that we are going to do this one way or the other. We're going to open doors to make it easier for you to do it yourselves without us getting involved. Please build the nimble, industry-friendly system that takes care of the American people. That's the challenge. It doesn't work the way that we intend as was outlined earlier, we need to trust, but verify.
Ally Goelz (36:34):
Hi. Ally Goelz with the Washington Examiner. Thank you. Do you guys think that you're going to pursue legislation or regulation to codify this, even if the insurance companies are willing to comply and be meek right now?
Speaker 3 (36:48):
Absolutely. We've been working on this. Greg's been working on this for years now, and I think that we're very close. We've got the score, the CBO score down on it. And I do think that we owe it to our patients to go ahead and codify something.
Speaker 4 (37:05):
Yes.
Adair Teuton (37:08):
Hi, Adair Teuton, RealClearPolitics. And then I'm just wondering, since these are voluntary reforms, what incentives will HHS provide to ensure insurers actually comply and follow through? And then if not, what recourse will patients have if delays or denials persist?
Dr. Oz (37:23):
This is a very fast-moving process. We anticipate having in place rules that will protect patients. I shouldn't say rules. The industry having rules for themselves in place by the end of this calendar year. So seven months from now you're already going to be benefiting from these decisions if you're a patient.
(37:39)
We are confident that some companies will come along, others might not. We have the ability through the rules process to enforce pre-authorization if necessary. It is a process that is necessarily limited by a series of steps that's there to protect all Americans. In this case, unfortunately, it's going to slow down the implementation of prior authorization. That stated, I'm optimistic, hopeful, that we don't have to do that, but it's always in our back pocket if we need it. Thank you.
Speaker 4 (38:08):
Yes.
James Eustis (38:13):
James Eustis with RealClearPolitics. What are some specific metrics and deliverables that you're looking for from health insurance companies?
Chris Klomp (38:23):
We'd like to see meaningful reductions in code counts requiring prior authorization, including several of the obvious ones that we've talked about. A vaginal delivery, why is that a question mark in this day and age? You're shaking your head. I do too. I think most insurers do as well. There's opportunity to eliminate that.
(38:39)
That's actually not the set of metrics I think are most compelling and will be most felt by individual patients. It's the faxes and the phone calls that providers experience where they then experience uncertainty, often at that moment as was talked about by Dr. Oz and Secretary Kennedy and Eric, when they feel the greatest level of uncertainty, but also a despondence and despair and desire for knowledge and certainty and action, and they can't get it.
(39:08)
So I am most focused, I think we are most focused, on the set of metrics related to the process. One of the goals is that by 1-1-27, at least 80% of all prior authorization requirements will be adjudicated in real time at the point of care. That's a meaningful change in behavior. You're sitting with your provider. They're telling you the test that they want to order or the treatment plan that they'd like to issue. They put it into their EMR or their other software program through fire based standards that CMS has identified and promulgated throughout the system, and immediately let you know where you are.
(39:42)
And in the event that there isn't an approval, you have a transparent, clear timeline that you can hold your insurance company accountable for so that you can gain clarity. And that doesn't need to add to the burden of uncertainty. Those are the metrics that we care about. That's the patient experience, the beneficiary experience that we're focused on. This is why the secretary made this such a high priority early in the administration.
James Eustis (40:07):
What percent are we at now?
Chris Klomp (40:10):
What percentage are we of real-time, same-day adjudication? Low single digits. Yeah, it's a little bit complicated. You have to break down medical versus pharmacy, but it's low. And from a patient's perspective, exceptionally low. More than 50% of all prior authorizations are still paper-based using phones and faxes.,So you can imagine the timeliness of that.
Speaker 4 (40:30):
We have a last question right there.
Chelsea Cirruzzo (40:34):
Hi, Chelsea Cirruzzo with STAT News. Dr. Oz, insurers made a similar pledge in 2018 that wasn't quite lived up to. What's different this time around?
Dr. Oz (40:44):
Secretary Kennedy alluded to that. There was another effort in 2023. I think two things have changed. I mean, there's violence in the streets over these issues. This is not something that is a passively accepted reality anymore. Americans are upset about it. Secretary Kennedy made it very clear from the outset that we're going to deal with this issue one way or the other. We have legislation pending that would come in as well to codify some of these changes.
(41:07)
But I think the major factor is the industry realizes that some of the things that are pre-authorized just don't make any sense. And they now believe that because we could actually create a interoperable digital system of connectivity with very agreed-on standards, this actually could become a real-time process, which takes a lot of money out of the system.
(41:27)
They estimated earlier today that it costs between 35 and $45 per documentation of pre-authorization for the doctor's office, costs the same amount for the insurance company, for every single time. And there were 3.2 million documents last year for just Medicare advantage. So multiply the numbers and you begin to realize we're throwing money away on administrative costs just financially. We're also wasting people's times. And we have the technology today to actually address this in a meaningful fashion. But the most important reality is the administration has made it clear we're not going to tolerate it anymore. So either you fix it or we're going to fix it. And I think they wisely have decided that they should fix it. I'm looking forward to seeing the results.
(42:07)
Secretary Kennedy, thank you for giving us an opportunity.
Robert F. Kennedy Jr. (42:12):
Thank you, all.
Speaker 4 (42:12):
Thank you, everyone.
Robert F. Kennedy Jr. (42:14):
Thank you, all. I add one thing before closing. The digitalization and the interoperability of the system that this is incentivizing, will allow us to do what we ultimately want to do during this administration, which is to begin the transition to outcome-based care, to value-based care.
(42:36)
And Chris Klomp walked away from a billion-dollar company in order to join us here, and he wasn't interested in prestige or power or position or a salary. He's interested in changing the system. And we have from top to bottom in this agency now, these people who have come in here who are interested in only one thing, which is to make this system functional, to rationalize it, to make it work, to make our country healthy again. I'm very grateful to all of you for all the work, Congressman Murphy, Senator and Oz and Jake Levine and Chris Klomp and all the many people at this agency who have made this happen.
(43:28)
And I'm very, very grateful to the insurance CEOs for stepping up today. It was an extraordinary meeting. It was filled with people who were not complaining. They were welcoming this opportunity. They were showing their idealism. They're showing their belief in this country. Showing the idealism that got them into this industry of healthcare in the first place. And they feel that they have an opportunity to really transform this system in a monumental way that people have been fighting for years and do it without regulation, without government intervention, but doing it because of the goodness of American business.
(44:13)
And that was a very, very encouraging thing to me. And I'm very grateful to President Trump or the leadership that has inspired people to take these kind of steps with faith in our country and faith in our future. Thank you all very much.
Dr. Oz (44:36):
Good job.
Speaker 3 (44:36):
Good job.
Robert F. Kennedy Jr. (44:39):
Thank you.
Speaker 3 (44:39):
Yep, [inaudible 00:44:39].
