The recent commitment by the nation’s largest health insurers to cut red tape and accelerate care decisions by implementing long-overdue reforms to the prior authorization process is welcome news. What is most needed now, however, is solid evidence that payers will do what they’ve promised—along with a method to hold them accountable—to fix this overused cost-control measure that endangers patients, wastes resources and undermines the expertise of physicians.
If this latest pledge sounds familiar, it should. In 2018 and again in 2023, major health insurers outlined a structural overhaul of prior authorization to ensure safe, timely and affordable access to evidence-based care for patients, cut the administrative burden placed on physicians, and bring much-needed transparency to the process.
Multiple components of this latest pledge by health insurers are nearly identical to the commitments they made seven years ago, including reducing the number and scope of claims subjected to prior authorization, automating the process to speed responses while improving overall transparency, and protecting continuity of patient care.
Progress has been slow
Positive results from those prior efforts have been hard to find, however. The latest AMA survey (PDF) found that an overwhelming majority of responding physicians—more than 80%—said the number of prior authorization requests for medical services and prescription medications has increased over the past five years. Fully 75% of physicians said denials had increased over that same time frame. In terms of patient harm, more than three-fourths of physicians said the prior authorization process has led patients to abandon treatment, and nearly one-fifth reported that a patient has required hospitalization as a result.
Automation to improve transparency and efficiency has also lagged. Phone calls are still the most commonly used method for completing prior authorization requests, as the adoption of national standards for electronic transactions has lagged. Antiquated technology such as fax machines—relics of a bygone era—are still widely required by health insurers, further delaying care. On average, physician practices handle around 40 prior authorization requests each week, and nearly half have staff dedicated solely to handling this function.
Right-sizing is an AMA priority
As the physician’s powerful ally in patient care, the AMA has been fighting to streamline and simplify a process that has morphed from a rarely used tool intended to limit the use of expensive, newly introduced medications or treatments into a utilization management strategy that payers regularly invoke before patients can receive even the simplest generic medications or time-proven, evidence-based treatments.
Prior authorization hassles remain a source of endless frustration for me, my small staff and our patients in Flint, Michigan. Hassles may be too mild a term. Just a few months ago, a member of my staff had to call an insurer over a prior authorization issue because “Mukkamala” wasn’t coming up as a provider in their system. Even though I have been practicing for a quarter-century, my name failed to appear on the physician roster compiled by the largest insurer in my home state of Michigan. This is an isolated example, to be sure, but also a symptom of an unsustainable process that must be changed. To fully gauge the depth of this problem and the reforms we need, you can see other physicians share some of their very worst experiences with prior authorization.
Advocating for solutions
Turning around this situation to make it work better for all involved is at the heart of the effort outlined in late June by Mehmet Oz, MD, Administrator of the Centers for Medicare & Medicaid Services.
The six key reforms that the nation’s leading health insurers agreed to include:
- Standardizing electronic prior authorization requests.
- Reducing the number and scope of these requests.
- Ensuring care continuity when patients change health plans.
- Explaining denials and provide instructions for appeals.
- Speeding approval response times for patients and providers.
- Ensuring all denials based on medical necessity continue to be reviewed by a licensed and qualified clinician.
Fulfilling these commitments will fundamentally reshape prior authorization, improve patient outcomes and allow physicians to do what they do best: direct patient care.
Simple steps can make a huge difference. Consider the insurers’ pledge to standardize electronic requests, for example. This could mean placing one application icon on our computer screens that would launch a single prior authorization program for all health plans. Instead of 10 or 12 apps, each used by a different insurer, physicians or their staff members could click on just one icon to send all the necessary information to any payer.
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This type of standardization could also apply to the questions that physicians answer to secure authorization for certain tests or procedures. Now, different insurers pose different questions to grant approval for the same tests or procedures, which makes no sense; the medical science involved does not differ depending on who is paying for it.
The AMA intends to carefully monitor the implementation of these pledged reforms, gauge their impact, and do everything in our power to see that good intentions become concrete reality. Insurers can and should do much more to improve patient care than giving lip service to prior authorization reform. It’s time to act.
In any event, the AMA’s efforts to reform prior authorization are far from finished. We will continue to work closely with federal and state policymakers on legislative and regulatory solutions such as gold carding programs, which allow physicians who routinely have their requests approved for certain medications and procedures to skip prior authorization program for those treatments. And we strongly support legislation pending in Congress, the Improving Seniors’ Timely Access to Care Act, which would codify prior authorization reforms and enjoys bipartisan backing.
Patients and physicians have waited long enough for health plans to rein in their overzealous use of prior authorization. We approach their current pledge to do just that with cautious optimism, and reaffirm our commitment to work cooperatively and collaboratively with health plans to protect and benefit our patients.
