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Health Plans Reducing Pre-Authorizations by Trimming Lists, Trusting Docs

By Gregory A. Freeman  
   April 04, 2018

Waiting for prior authorization decisions for some medical care is not only irksome but can be dangerous to patients. Health plans are loosening the reins a bit.

With a strong push from the American Medical Association (AMA), health plans are beginning to relax the prior authorization requirements that have long frustrated consumers. Physicians are united in their concerns that prior authorization can threaten patient care, so insurers are relenting and relying more on doctors' good judgment.

A recent AMA survey found that 92% of physicians say prior authorization programs have a significant (61%) or somewhat (31%) negative impact on patient clinical outcomes. Pre-authorizations have vexed consumers and physicians alike for decades, but the problem has gotten worse in recent years, says AMA Chair-elect Jack Resneck Jr., MD.

"This is a tremendous burden that's taking up a lot of time that we could be spending with patients. But it's not just a burden for us. It's also detrimental to our patients," Resneck says. "In my own practice, it's not just the brand-new, expensive drugs where we would expect to have prior authorization. It's happening for even the generic, inexpensive drugs. It's not always clear it will require a pre-authorization until the patient gets to the pharmacy, and then that can result in several days delay in care."

Some patients even have to go through prior authorization multiple times for the same medication when they try to refill a prescription, Resneck says. The patient may have changed health plans, or the medication protocols within the same health plan might have been updated.

Insurers eventually authorize most requests, Resneck says, but that does not diminish the impact of the required paperwork, phone calls, negotiations, and the delay in a patient's care.

The AMA survey examined the experiences of 1,000 patient care physicians, and 64% of physicians report waiting at least one business day for prior authorization decisions from insurers. Thirty percent said they wait three business days or longer.

In addition to 92% of physicians who said that the prior authorization process always (15%), often (39%), or sometimes (38%) delays patient access to necessary care, 78% said prior authorization can always (2%), often (19%), or sometimes (57%) lead to patients abandoning a recommended course of treatment.

Two days per week for authorizations

Eighty-four percent of physicians surveyed said the burdens associated with prior authorization were high or extremely high, and 86% percent said the burdens associated with prior authorization have increased significantly (51%) or increased somewhat (35%) during the past five years.

A medical practice completes an average of 29.1 average total prior authorization requirements per physician every week, which takes an average of 14.6 hours to process—the equivalent of nearly two business days, the survey found. The administrative burden is so high that 34% of physicians said they rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.

Gregory A. Freeman is a contributing writer for HealthLeaders.

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