Medicare Pay, Prior Auth, and More: A Q&A With the AMA’s President-Elect

As the president-elect of the American Medical Association (AMA), Bobby Mukkamala (pronounced “moo-COM-ala”), MD, an otolaryngologist in Flint, Michigan, will be working on the association’s top priorities like better Medicare reimbursement for doctors and decreased use of prior authorization by insurers, but he also has another top priority of his own.

MedPage Today Washington Editor Joyce Frieden spoke by phone with Mukkamala to ask about his plans for what will likely be a busy year for the AMA. This interview, which was conducted with a public relations person present, has been edited for length and clarity.

Tell us a little about your background.

Mukkamala: I’m of Indian heritage. My parents moved to the U.S. from India in 1970 [to do their medical residencies]. A short story here: my dad took a job in Flint, Michigan, doing his residency training in radiology, because it paid a few hundred dollars more than this other job at a place called Johns Hopkins University Hospital. He had never heard of either one of them, so he took the job that paid a couple bucks more and ended up in Flint instead of Baltimore. The rest is history, as they say.

I grew up here in Flint. I started in Flint public schools, and then my parents thought I needed more discipline and I switched to Catholic school, and so I went through the parochial school system here, and graduated from Powers Catholic High School in Flint.

I went to the University of Michigan for undergraduate and medical school, and met my future wife there, Nita Kulkarni. She’s an ob/gyn. We both ended up doing our residency training in Chicago. And then Nita [became pregnant with twins] in our last year of residency, and [she came with me] back to Flint. That was 24 years ago, and so we’ve been in practice together, kind of an odd combination of ENT and ob/gyn.

So you will be the second AMA president in a row that’s an ENT [like the current president, Bruce Scott, MD].

Mukkamala: Good observation. My understanding is we’ve never had an ENT as president before, so we’re making up for lost time.

How did you get interested in medicine?

Mukkamala: With my parents being physicians and being sort of “generation zero” in this country, they found happiness and success in this country through the medical profession, and so they basically said that that’s what I was going to become.

I used to really enjoy watching Peter Jennings on the ABC Evening News back in the day, and I told [my parents] I wanted to be a journalist. They grounded me until I changed my mind. Then, when I got into a 7-year [combined undergraduate/MD] program at Michigan, and I had a guaranteed admission, it seemed foolish to not take advantage of that. So I went into medicine because my parents didn’t give me another choice. And now here I am.

And how did you decide on otolaryngology?

Mukkamala: Initially, I was ready to go into cardiothoracic surgery at my third year of medical school, and I had all my recommendation letters lined up from people that were well known in the field. And then I did my otolaryngology rotation and loved it, because I was taking care of people that were both newborn kids all the way to the most senior of senior citizens and everything in between, both genders, some time in the operating room, and plenty of time in the office. So it was a nice balance of the entire spectrum of medicine.

And I loved the intricacy of the anatomy as well. The head and neck anatomy was just something that was so exciting to me, to learn and to work in that area surgically. So I switched at the last minute and became an otolaryngologist, and I have no regrets.

So where did the AMA fit into all this?

Mukkamala: When Nita and I started our private practice, we basically found some space to rent, and we hired some office staff, and we went right to work and started to see patients and take care of them, and then submitted the claims to insurance companies — and we were met with a bunch of denials.

I was thinking we were doing everything right, but we had not learned about the nature of billing for medical services in medical school. We used to print these pink and white paper forms and you know, your form could be just a little bit off, and they would deny the claim.

It was quite concerning and irritating to me. So, I decided, “I’m going to go to law school. I’m going to get my law degree, and I’m going to sue for each of these denied claims in small claims court.” That was my brilliant plan. Then someone wisely told me, “You know, you don’t need to do all that. You can join the Michigan State Medical Society. We can take care of these things for you, and you can keep doing what you enjoy doing, and we will take care of the billing aspect and pursue these issues.” And so then I thought, “Oh, that’s great.”

So I started to go to those meetings and realized the benefit of organized medicine to help physicians take better care of their patients. And then I was hooked. I went through the process of chairing the Young Physician Section at the Michigan State Medical Society, joining my county medical society, and joining the AMA as a representative of Michigan. I ran for the [AMA’s] Council on Science and Public Health, and I served in that capacity for 8 years, and then I was on the Board of Trustees for 7 years, and then there was the recent election. So that was my path.

What are you hoping to learn during your year as president-elect?

Mukkamala: I’m still very much in the mode of learning what physicians are going through as we are trying to navigate healthcare in this country … [During the election process] there were more than 20 groups within the AMA that wanted to interview me, and I eagerly participated in those, because you learn a lot from the questions they ask, whether it’s issues of insurance consolidation, or Medicare, or accessing care, or Medicare payment in a time where our cost of doing practice has gone up so dramatically. Each of these questions shares with me what’s on people’s minds.

So what will your main priorities be?

Mukkamala: The main priority that I have is [improving] Medicare reimbursement. All payments from all insurance companies tend to be based on what Medicare does … Where Medicare goes, there goes everybody. And right now, Medicare isn’t going in the right direction.

Nita and I, in our practice, our costs of doing business have gone up by more than 20% just in the past 2 or 3 years in the post-COVID era, related to human resources and things like that. And yet, we just narrowly avoided a 3% cut, only to escape with a 1.7% cut in Medicare last year. So when I look at that current situation, it is not sustainable, and that’s why I’m very excited about the possibility of fixing it for good by tying Medicare payment to physicians to an economic index.

Any other issues — maybe something that’s not on everyone’s radar right now?

Mukkamala: One thing that I mentioned a lot is lack of medical record interoperability. For example, Nita, my wife, will do robotic surgery in the morning at one of our local hospitals — cutting-edge stuff — and then come back to our office and fax the operative note on that patient to the primary care physician. I joke that it’s like George Jetson and Fred Flintstone living in the same era.

Another example: we have a lot of folks in Michigan who winter in Florida. When I see a patient up here that has a severe allergic reaction to a medication that caused airway swelling and [ends with] a trip to the emergency room, and I document all that in the electronic health record, when that patient goes to Florida and they’re seeing a physician there, if the physician doesn’t ask that question, and the patient doesn’t remember to say, “Oh, by the way, don’t prescribe me this, because it did this to me in Michigan,” there’s no way that that physician knows because there’s no interoperability of that critical piece of data. And that’s a shame.

The fact that here we are in 2024 and it relies on a patient remembering to tell somebody this when it’s all digital — because of the compartmentalization of that health information, because of the multiple vendors that relate to EHRs, like Epic and Cerner, not communicating and not being interoperable, that’s inexcusable. I would love to see more pressure on these vendors to solve that problem, because right now that pressure is on third parties to create programs to make these things interoperable. And that’s not right.

What are your thoughts on prior authorization?

Mukkamala: In my office staff, there’s a person who sits in a room on their own all day so that anything that we order, whether that’s medication, whether that’s a scan, whether that’s a procedure, they immediately start that prior authorization request process. And this is a job description that exists in every medical office, and that’s just such a waste of resources.

What about the idea of “gold carding” doctors whose prior authorization requests are almost never turned down, so that they are exempted from the process?

Mukkamala: Gold carding is something that would be welcome. What’s interesting is that in Michigan, we have something called the “uplift” — if you have good performance, if your metrics are good relative to your peers, then you get a 10% uplift in payment from the insurance company. So here, on the one hand, is this insurance company telling me that I’m in the top third, and that, as a reward for that, I’m going to get a 10% uplift, and yet, I’m also having to go through prior authorization.

One other question: how will you juggle your AMA duties with your medical practice?

Mukkamala: That is a wonderful question, and that’s the only thing about this that keeps me up at night, because I’m in solo practice, and there’s no way I’m going to be able to entice an otolaryngology graduate or any otolaryngologist to come to Flint, Michigan. I joke — but it’s not even a joke — that my best hope of finding an otolaryngologist to join me is for my wife and I to have another kid, wait till they finish medical school and ENT residency, and come back to join my practice. That’s my best hope.

I’ve already talked to my patients — I started to let them know about this possibility. I know my patients, and I see them on a daily basis out in the community. They know that if it’s going to take an extra few weeks to get in to see me to evaluate their issue, it’s not because I’m out on the golf course; they know that I’m working on their behalf around the country, trying to improve healthcare. Most of them expressed a sense of pride and gratitude and a willingness to wait a little longer to come in to deal with their ENT problems, and I’m grateful for their flexibility.

Thanks very much for speaking with us today!

Mukkamala: Glad to do it.

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