Prior Authorization Programs a 'Nightmare,' Need Reform: AMA

Megan Brooks

March 20, 2018

Prior authorization programs delay access to needed care and have a negative impact on clinical outcomes, according to a survey of practicing physicians released Monday by the American Medical Association (AMA).

"Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment," AMA Chair-Elect Jack Resneck Jr, MD, explained in the release.

"In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls, and bureaucratic battles that can delay or disrupt a patient's access to vital care. In my own practice, insurers are now requiring prior authorization even for generic medications, which has exponentially increased the daily paperwork burden," said Resneck.

The survey results support a growing recognition that prior authorization programs must be reformed, the AMA said in the release.

Consequences for Patients

The AMA surveyed 1000 physicians who provide patient care. Nearly two thirds (64%) report waiting at least 1 business day for prior authorization decisions from insurers, and close to a third (30%) report waiting 3 business days or longer for these decisions.

The long wait times for preauthorization for medical care have consequences for patients. More than 9 in 10 physicians (92%) surveyed report that the prior authorization process delays patient access to necessary care, and nearly 4 in 5 (78%) say it can sometimes, often, or always lead to a patient abandoning a recommended course of treatment.

Eighty-four percent of physicians say the burdens associated with prior authorization are high or extremely high, and 86% believe the burdens associated with prior authorization have increased during the past 5 years.

According to the survey, every week, a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process, or nearly 2 business days. To keep up with the administrative burden, about a third of physicians (34%) rely on staff members who work exclusively on the data entry and other manual tasks needed for prior authorization.

The AMA is working with other key stakeholders to reform prior authorization processes. In January 2017, the AMA, in conjunction with 16 other associations, urged health plans, benefit managers, and others involved in utilization review to reform prior authorization requirements related to medical tests, procedures, devices, and drugs.

The AMA-led coalition is calling for an industry-wide reassessment of prior authorization to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and to reduce the administrative burden. More than 100 other healthcare organizations have supported those principles, the AMA says.

In January 2018, the AMA joined the American Hospital Association, America's Health Insurance Plans, the American Pharmacists Association, the Blue Cross Blue Shield Association, and the Medical Group Management Association in issuing a consensus statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

Earlier this month, the AMA and Anthem announced a collaboration that would include identifying ways to streamline or eliminate low-value prior-authorization requirements and implement policies to minimize delays or disruptions in the continuity of care.

The AMA also recently produced and released several educational videos on prior authorization reform, which are available online.

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