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Physicians: Prior Authorizations Lead to Patient Care Delays

Analysis  |  By Alexandra Wilson Pecci  
   June 23, 2020

Since payers won't enact agreed-upon prior authorization reforms on their own, legislation is needed, says the American Medical Association.

Physicians say prior authorization continues to interfere with patient care and can lead to adverse clinical consequences, and 16% of physicians say that the process has actually led to a patient's hospitalization, according to a survey by the American Medical Association (AMA).

Despite a consensus statement issued more than two years ago by the AMA, two trade organizations representing payers, and other stakeholders, there has been little progress in reforming the prior authorization process, the AMA contends.

The consensus statement included five agreed-upon reforms that the AMA says its survey shows haven't been implemented. They are:

1. A selective application of prior authorization: Only 7% of physicians report contracting with health plans that offer programs that exempt providers from prior authorization, despite the consensus statement's position that insurers should exempt physicians with prescribing patterns that meet evidence-based guidelines or who have high approval rates from prior authorization.

2. Prior authorization program review and volume adjustment: Most physicians (87% and 82%, respectively) report the number of prescription medications and medical services needing prior authorization has grown over the past five years. However, the consensus statement said that insurers should regularly review drugs and services subject to prior authorization and remove those that that show "low variation in utilization or low prior authorization denial rates."

3. Transparency and communication regarding prior authorization: The AMA survey showed that 67% of physicians report that it is difficult to determine whether a drug or service requires prior authorization. That's despite the consensus statement that insurers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes."

4. Continuity of patient care: Although insurers should "minimize disruptions in needed treatment," and "repetitive prior authorization requirements," 83% of physicians report that prior authorization interferes with continuity of care, such as resulting in missed doses or interruptions in chronic treatment.

5. Automation to improve transparency and efficiency: Phone and fax are still the most commonly used methods for completing prior authorization requirements, physicians say, despite the consensus statement's call for speeding the adoption of existing national standards for electronic transactions for prior authorizations.

Other survey findings include:

  • 64% of physicians report waiting at least one business day for a prior authorization response
  • 29% report waiting at least three business days for a prior authorization response
  • 91% of physicians report prior authorization-related patient care delays
  • 24% report that prior authorizations have led to a serious adverse event for a patient in their care
  • 74% report that prior authorizations can at least sometimes lead to treatment abandonment
  • 86% report prior authorization burdens have increased over the past five years
  • 30% of physicians have staff who work exclusively on prior authorizations

The AMA says that since payers won't act on their own, legislation is needed, pointing to H.R. 3107, "The Improving Seniors' Timely Access to Care Act," which is bipartisan legislation introduced by Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall, M.D. (R-KS), and Ami Bera, M.D. (D-CA).

It would require Medicare Advantage plans to abide by many of the concepts outlined in the consensus statement, such as streamlining and standardizing prior authorization and improving transparency of health insurer programs. 

A bipartisan majority of more than 219 members of the House of Representatives has already co-sponsored the bill, the AMA says.

"Prior authorization is a common management tool, but the current landscape doesn't provide the best utilization of it, resulting in physician burdens and patient access issues," Marshall said in a statement. "Our bill will bring Medicare Advantage to the 21st century by streamlining and modernizing the prior authorization process."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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