Physicians report that prior authorization delays needed care, results in adverse patient events, and poses excessive administrative burden.
Prior authorization of medical treatments and services has a negative impact on patients and physician practices, a recent physician survey conducted by the American Medical Association (AMA) found.
Payers often require prior authorization for medical treatments and services. Physician practices have been critical of the impact of prior authorizations for many years.
The recent survey featured 40 questions that were administered online in December. More than 1,000 practicing physicians participated in the survey, with 40% working as primary care physicians and 60% working as specialists.
The survey features several key data points.
- 93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes)
- 82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes)
- 34% of physicians reported that prior authorization has led to a serious adverse event for a patient
- 24% of physicians reported that prior authorization has led to a patient's hospitalization
- 18% of physicians reported that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
- 29% of physicians reported that prior authorization criteria are rarely or never evidence-based
- Physicians and their staff spend an average of 13 hours per week processing prior authorizations
- 40% of physicians reported having staff who work exclusively on prior authorizations
- 88% of physicians reported that the administrative burden associated with prior authorization is high or extremely high
- 51% of physicians reported that prior authorization has interfered with a patient's ability to perform his or her job responsibilities
Interpreting the data
It is alarming that 93% of physicians surveyed said prior authorization is associated with care delays, AMA President-elect Jack Resneck Jr., MD, told HealthLeaders.
"An archaic prior authorization process can have alarming consequences for patients when evidence-based care is delayed or denied. As physicians face recurring paperwork requests, multiple phone calls, and hours spent on hold, patients' lives can sometimes hang in the balance until health plans decide if needed care will qualify for insurance coverage. Not only can the patient's condition decline during this waiting time, but the stress and anxiety of not knowing if they will receive the care they need exacts an emotional toll," he said.
It is also concerning that one-third of physicians reported that prior authorization resulted in instances of patient harm, Resneck said.
"Despite evidence that prior authorization can be a hazardous administrative obstacle to patient-centered care, it remains unsettling that meaningful reforms to protect patients have been deferred, disregarded, and sometimes obstructed by health insurers. The fact that over one-third of physicians report a patient has experienced a serious adverse event related to prior authorization indicates that our current system is broken: coverage requirements should not be preventing access to care and leading to negative clinical outcomes. Beyond the distressing human costs of prior authorization shown by these data, the results also call into the question if prior authorization really reduces overall medical costs. If delayed care results in a patient's hospitalization, no one—the health plan, the employer, nor the patient—is saving money," he said.
Prior authorization needs to be reformed and "right-sized," Resneck said. "There is growing agreement across the entire health system that prior authorization is overused without justification and needs to be right-sized. Requiring prior authorization for drugs or medical services with consistently high approval rates—what many would call 'low-value' prior authorizations—is wasteful for physicians, patients, and health plans. Similarly, burdening physicians with a history of following evidence-based guidelines and/or high prior authorization approval rates adds unnecessary administrative costs to our healthcare system."
Prior authorization is an excessive administrative burden on physician practices, he said. "The AMA's survey data illustrate the current excessive volume of prior authorization requirements. Practices report completing an average of 41 prior authorizations, per week per physician, and this workload for a single physician consumes nearly two business days of physician and staff time. In addition, 40% of physicians report hiring staff just to complete prior authorizations. If we are looking for ways to reduce unnecessary administrative costs in healthcare, prior authorization is a clear target."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
More than 90% of physicians reported that prior authorization led to delays of necessary patient care.
One-quarter of physicians reported that prior authorization has led to a patient's hospitalization.
Half of physicians reported that prior authorization has interfered with a patient's ability to perform his or her job responsibilities.