“But the bottom line is, when we put our heads down and we are trying to take care of that patient in front of us, ironically we're not as effective as if we were able to use our voice to let the leaders and the lawmakers and policymakers know what needs to be fixed.”

Dr. Tina Shah is a pulmonary critical care specialist and chief clinical officer of Abridge, a technology company that leverages generative AI to support physician note taking and clinical documentation.

She’s also a leading physician advocate for healthcare policy change and one of the key individuals who recently helped to enact prior authorization reform in New Jersey which is set to take effect in January 2025.

The legislation, called the “Ensuring Transparency in Prior Authorization Act,” was passed earlier in 2024 and will require health insurance companies to decide on prior authorization requests within 24 hours for urgent cases and within three days for all other patients.

This significant development is poised to alleviate one of the major pain points for physicians and patients. Indeed, according to a recent survey by the American Medical Association (AMA), 90% of physicians have had patients delay their care because of prior authorization, and one third of physicians say this delay had serious health consequences for their patients.

Working with a coalition of physician allies, the Medical Society of New Jersey, and the AMA, Tina took matters into her own hands. In this episode of How I Doctor, Tina speaks with Offcall co-founder Dr. Graham Walker about her journey into policy work and the steps she took to bring about prior authorization reform. (For more information about Tina’s work to reduce physician burnout using AI technology, you can also listen to a previous episode of How I Doctor here.)

With 30 additional prior authorization reform bills currently making their way through state legislatures, Tina’s playbook can serve as a catalyst for other physicians to accomplish reform in their own state. Even more, Tina’s example teaches a broader lesson: That when physicians take the time to band together, we can enact real change.

“I think this is an example of what we're leaving on the table,” she shared. “Yes, it takes more work, but we definitely aren't voiceless, and I can attest to that as a doctor that lives in New Jersey.”

Here are five tactical steps you can take as a physician to bring about policy reform in your state, for the benefit of your local practice, your colleagues and your patients:

1. Make Time for Advocacy

“When we put our heads down and we are trying to take care of that patient in front of us, ironically we're not as effective as if we were able to use our voice to let the leaders and the lawmakers and policymakers know what needs to be fixed.”

Tina’s first lesson is perhaps the simplest: It’s critical to set aside time for advocacy work. But that’s also one of the most difficult lessons for busy physicians, something that Tina admitted: “Physicians work extremely hard, and to ask a doctor to do yet another additional task is a tall ask.”Despite this reality, this is the only way to get real change accomplished. “I think that's the catch-22 of it all,” said Graham. “We are so busy trying to manage patients that we don't even have time to advocate for ourselves when there's a bill and when we need it most.

2. Build a Diverse Coalition of Allies

“The lowest hanging fruit is, “Can you connect with your state medical society? Your specialty [society] is good too. But I will just say numbers play a big role here. There's a playbook for how we can take one voice and make it really loud.”

Once Tina decided to make time and devote herself to the cause, it was time to build a coalition of allies to help. Over the course of 18 months, she worked with the Medical Society of New Jersey, the AMA, and a number of physician leaders, including Dr. Nisha Mehta, Dr. Kedar Mate, Dr. Pedja Sojicic, and Robyn Begley, chief executive officer of the American Organization for Nursing Leadership (AONL).

Tina’s theory of change was rooted in the power of numbers: “We had this idea of a theory of change, and the question was, could we mobilize enough patients and clinicians together to garner enough support that we could get this bill passed?”

3. Grow Your Coalition Through a Smart Ground Game

“Even though by individuals we're small voices, we can do really big things.”

With the coalition in place, Tina realized that the key to enacting real change would be developing a strategic ground game to multiply her coalition and bring more leaders into the fold. She shared that her team met almost every week and gradually worked to expand: “What we did is we then found five more people, and we found a very small group of leaders that could then organize more people. And so one of the pieces was can we enact a ground game where we have milestones?”

That ground game even involved old fashioned door-knocking. “I remember a really good friend mobilized her entire division and went door to door, even trying to sign up people to fill the petition out. So there's a ground game that has to be done.”

4. Leverage Social Media to Amplify Your Effort

“All of a sudden it changed from we're doctors, we're working really hard, we're really tired, our patients are also hitting this huge roadblock, and turning it into something positive where I wonder what the height of the stack of letters would've been had we printed it out.”

In addition to a traditional ground game, Tina leveraged the power of social media. One of the people she turned to was Dr. Glaucomflecken, who made a video about prior authorization in New Jersey. “It got so many hits that when we shared it back with all of the parties, especially the legislators, all of a sudden the Medical Society of New Jersey had more leverage to actually get the critical pieces of the bill passed because we had our ground game, and we had 10,000 letters that got sent to legislators, but we also had the social media angle where there were hundreds of thousands that had viewed these posts and also had commented,” Tina shared.

In a previous episode of How I Doctor, Dr. Glaucomflecken shared what physicians can do to take back power and get more engaged in creating change in their communities.

5. Always Be Politically Strategic

“We were really, really strategic. In fact, it wasn't that we were trying to convince the entire legislature, that's overwhelming to vote for this, but you have to do the political ground game too and use allies that understand how your state government works.”

Another ingredient to Tina’s success was the importance of understanding local politics and how to get a bill passed in New Jersey. “There were four key stakeholders we needed to really convince,” she shared. In Tina’s case, partnering with the Medical Society of New Jersey helped her to understand who these individuals are: “[These] people play the advocacy game all day, every day.”

To connect further with Tina, follow her writing on LinkedIn and on her website.

To make sure you don’t miss an episode of How I Doctor, subscribe to the show wherever you listen to podcasts. You can also read the full transcript of the episode below.

Offcall exists to help restore balance in medicine and improve the wealth and wellbeing of physicians. Sign up for Offcall here to bring about more physician compensation transparency and join our physician movement.

Transcript

Dr. Tina Shah:

But the bottom line is when we put our heads down and we are trying to take care of that patient in front of us, ironically we're not as effective as if we were able to use our voice to let the leaders and the lawmakers and policymakers know what needs to be fixed.

Dr. Graham Walker:

Welcome to How I Doctor, where we're bringing joy back to medicine. Hi, it's your host, Dr. Graham Walker. As we close out the year, we wanted to take time to celebrate a big win for physicians and patients: prior authorization reform in New Jersey. Dr. Tina Shaw was instrumental in getting a bill passed in her state that goes into effect on January 1st.

The bill requires insurance companies to respond to prior authorization requests in 24 hours for urgent cases, and 72 hours for everything else. If they don't, it's automatically approved. It also requires physicians reviewing the request to be in your same specialty. This will remove layers of inefficiency, and make a real difference in the state.

Working with a coalition of physician allies, her state medical association, and the AMA, Tina took matters into her own hands and developed a playbook for change. She shares some of the tactical steps that any physician can take no matter who you are to change legislation to benefit your local practice, your colleagues and your patients.

What I love so much about this episode is the larger lesson that it teaches: When physicians take the time to band together, we can enact real changes to make things better. Wishing everybody a happy and healthy holiday, and we'll have much more to share from Offcall and How I Doctor in 2025.

What Prior Authorization Reform in New Jersey Means for Physicians and Patients

GW:

I think one of the coolest things that you've done was your victory and support in New Jersey dealing with prior authorization. What exactly changed in New Jersey?

TS:

So in New Jersey, like many other states, we have very similar problems where it seems that it just takes a very long time to get a response when a prior authorization is submitted. Often times, you're doing peer-to-peers where you really don't have a peer. This person might not be a doctor, they might not even be in the same specialty, and they may not have been practicing in the last couple of years and even understand what you're trying to get.

Some pressure was starting to build. There were a couple of really striking news articles that came out sort of saying, while prior authorizations have been touted by some to be able to help us have right time, right care, there are many instances in which patients are literally having delays of care, and this is costing doctors' offices close to three out of five business days' time. So like two FTE really focusing on just to manage all this.

In New Jersey, we decided to try a test. So with other people – and I would love to give a couple of shout-outs to my co-collaborators.

GW:

Shout them out.

How Dr. Tina Shah Built a Coalition of Allies to Change Healthcare Policy

TS:

I'll mention Nisha Mehta from Physician Side Gigs, Kedar Mate from the IHI, Pedja Sojicic from Harvard, and Robyn Begley actually from the American Hospital Association, and a couple others, and a ton of people from New Jersey. We had this question, and the question was, could we actually do something to move the needle to where when someone actually has health insurance and when a doctor and the patient decides a treatment needs to be given, could we actually get it?

So this was 18 months of work, and we had this idea of a theory of change, and the question was, could we mobilize enough patients and clinicians together to garner enough support that we could get this bill passed? So we had some of the raw ingredients. We had a bill that was already at the state legislature. In fact, it was being co-sponsored by a physician, but interestingly enough, the bill co-sponsors weren't even hearing from doctors that this is important.

We had a bunch of doctors and patients in the field that were feeling the pressures and the difficulties with prior auths, and we had an expert in our group who has led political change and healthcare change in other countries. So we said, “Hey, can we take that playbook and can we apply it to a state in the United States for a healthcare issue?”

GW:

The legislatures were not hearing from physicians. And that just really resonated with me because I think that's the catch-22 of it all is we are so busy trying to manage patients and fill out the three business days of prior auth, that we don't even have time to advocate for ourselves when there's a bill and when we need it most.

Working With the American Medical Association and Medical Society of New Jersey to Enact Change

TS:

Yes, you're so right. Physicians work extremely hard, and to ask a doc to do yet another additional task is a tall ask that I don't think either of us wants to make. But the bottom line is, when we put our heads down and we are trying to take care of that patient in front of us, ironically we're not as effective as if we were able to use our voice to let the leaders and the lawmakers and policymakers know what needs to be fixed. So I think this was a tough one. I'm not sure if you're part of your California Medical Society, but I'm part of the Medical Society of New Jersey, and this is why those societies exist, because they testify when we're in clinic.

What was great was actually helping the medical society, which had drafted the bill coming off of model legislation that the AMA had written. And so they adapted it for Jersey and they were testifying, but it's a classic battle between two stakeholders, and in this case it was the medical community represented by the state medical society, versus a state health insurance advocacy group. And you can guess at who has more resources.

GW:

And who's maybe more organized too.

TS:

That's right. So it really argues for the sentiment that even though by individuals we're small voices, we can do really big things. And so what this took was a team that was meeting almost every week. And what we did is we then found five more people, and we found a very small group of leaders that could then organize more people. And so one of the pieces was can we enact a ground game where we have milestones?

Working With Dr. Glaucomflecken to Enact Healthcare Policy Change

TS:

So I remember a really good friend of mine who works in the Robert Wood Johnson Healthcare system mobilized her entire division, and especially her nurse in the clinic that was taking care of prior auths, and she went door to door, even trying to sign up people to fill the petition out. So there's a ground game that has to be done, but it doesn't mean that one person has to do it all.

The second thing I'll say that was really neat was leveraging social media. I got to give a shout out to my boy Dr. G because we actually connected with him, we explained what we were trying to do in New Jersey, and for those that haven't followed Dr. Glaucomflecken, he made a video talking about what we were trying to do in New Jersey and it got so many hits that when we shared it back with all of the parties, especially the legislators, all of a sudden the Medical Society of New Jersey had more leverage to actually get the critical pieces of the bill passed because we had our ground game, and we had 10,000 letters that got sent to legislators, but we also had the social media angle where there were hundreds of thousands that had viewed these posts and also had commented.

So all of a sudden it changed from we're doctors, we're working really hard, we're really tired, our patients are also hitting this huge roadblock, this common roadblock of prior auths, and turning it into something positive where I wonder what the height of the stack of letters would've been had we printed it out.

But having that virtual visual on social media, and then it being the vector that not only fired up our legislators that co-authored the bill, I think we had a near unanimous vote. There was only one person that voted against the bill, and it's going into effect on January 1. So if you live in New Jersey and you practice in New Jersey, and with a small asterisk, this is about health plans that are regulated at the state level so for example, that doesn't include Medicare. If you have a patient and it's an urgent prior auth, there's a 24-hour turnaround and if you don't hear back, then it's approved. If it's not urgent-

GW:

Automatically approved, yeah.

TS:

That's right. If it's non-urgent at 72 hours. We have actual peer to peers. It has to be a doctor of the same specialty or a doctor that hase the same knowledge of exactly what the procedure or treatment is, and they have to have practiced New Jersey in the last five years.

GW:

Oh my God.

TS:

So these are just some examples.

GW:

Yeah.

TS:

Yeah, I think this is really going to make tangible benefit, but I think this is an example of what we're leaving on the table. Yes, it takes more work, but we definitely aren't voiceless, and I can attest to that as a doctor that lives in New Jersey.

GW:

I don't think people have really taken in that level of detail about what you were able to accomplish. I would also say that that seems like a pretty fair expectation for prior auth, right? You could easily make an argument there shouldn't be prior auth at all. Hearing those examples that you said, it's hard to argue that that's an unfair expectation from the health insurer. I think it's a really good example that we are physicians, we do have a voice, we do have power, we are stronger together. I think as well, I wrote down kind of your recipe. I think you said you need a goal and a vision. You need leaders who are going to organize everybody else, you called them ring leaders. You need groundwork. You need people that are going to put in hours of time that is unpaid to change things. You need to be able to communicate the vision and what you're trying to accomplish. Shout out to Dr. G again, sounds like he had a huge piece in that. It's a great example of how social media can massively influence things.

The Importance of Being Strategic And Understanding Politics as a Physician

TS:

That's right. And one of the things that I forgot to mention was that we were really, really strategic. In fact, it wasn't that we were trying to convince the entire legislature, that's overwhelming to vote for this, but you have to do the political ground game too and use allies that understand how your state government works. And we had actually narrowed it down to only four. There were four key stakeholders we needed to really convince.

GW:

And then if you were able to convince them, the rest would fall in line?

TS: 

That's right. And obviously everyone has a vote on all of these bills, but by that I mean there were certain leaders that were say, let's say the chair of a committee in which the bill was being discussed. A particular leader that represented a district that was extremely powerful that then could easily catalyze other legislators from other districts. So a lot of this comes from partnering with your state medical society, and people that play this advocacy game all day every day are really trying to target the few legislators that were mission-critical for this bill.

GW:

I always try to bring it back to a medical example because I think our audience of physician listeners, it always helps them. So I could imagine if you think somebody has, I don't know, spontaneous coronary artery dissection, you're probably going to want to ask one of the experts who's seen 1,000 cases or 100 cases of it. You're not going to just randomly be like, "Oh." You're not going to ask a nephrologist or an infectious disease doctor, "Hey, what do you think? Do you think this could be SCAD?" It's like, no, we of course you're going to ask a cardiologist, and they're probably going to find their cardiology buddy who's like their main spontaneous coronary artery dissection guru to answer this question, because they're the person that is going to... Everyone's going to go to, and everyone's going to listen and trust on.

TS:

I think you got it right. We don't have time to create things ourselves. Why would you reinvent the wheel when all it takes is figuring out who knows? And imagine the audacious task of, audacious action of emailing your state legislator or the person that has an MD that's in the State House or an RN just saying, "Hey, can we chat? I practice in our great state. I've got some ideas," and they'll take your call.

GW:

Yeah, I was a social policy major in college, so I am a similar policy person. Can you just give me the three-minute download on how you decided to combine medicine, or when you decided to combine medicine with policy and government work as well?

How Dr. Tina Shah Became Interested in Healthcare Advocacy and Policy Work

TS:

It wasn't premeditated, but what I can tell you is I went through residency and I started to get a little educated. In fact, I took a break between second and third year of residency and I did an MPA, and that gave me a foundation of what is U.S. healthcare, how does it work? I think the biggest thing that happened to me is that by no fault of the particular place where I trained, which was University of Chicago, I was a pulmonary and critical care fellow in the hardest time of my life professionally, and I got burned out.

And what that did was caused me to soul search. And I ended up connecting with organized medicine. In my specific case, it actually was the AMA because a friend of mine was telling me, "Hey Tina, if you go to the American Medical Association, you know your voice is really big. I know you don't feel like you have that much of a say as a trainee, but it's very different when you're at that level."

And in my first year of being an active AMA member, I got to sit down with a U.S. Senator from Illinois, which is where, my state at the time, and we talked about healthcare, and we talked about increasing residency funding slots. So I got this almost immediate hit of join organized medicine, get trained up to learn how to be a very, very adapted advocacy, and see what else there is in the world beyond your bubble.

So for others that are listening, I would say the lowest hanging fruit is, “can you connect with your state medical society? Your specialty is good too. But I will just say numbers play a big role here in terms of membership or the AMA, because again, there's a playbook for how we can take one voice and make it really loud. So I think that was probably the thing that shifted me the most. But there are many ways to get involved, and the easiest is what's in your backyard.

GW:

Tina, thank you. It's been really such a pleasure to get to talk with you again. And thanks for taking the time away from your practice and students and everything to spend time with us today.

TS:

It's my pleasure. Thanks for having me.

GW:

Thanks for joining me today. For interviews with physicians creating meaningful change, check out offcall.com/podcast. Make an account on Offcall to confidentially share your details about your work, and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been, and continues to be, Dr. Graham Walker. Stay well, stay inspired, and practice with purpose.