We must fix prior authorization to protect our patients


AMA News Wire

We must fix prior authorization to protect our patients

Jun 18, 2024

Across the country, physicians see firsthand the dangerous, harmful—and sometimes deadly—consequences of prior authorization.

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Payers erect roadblocks allegedly designed to save money for the health system and protect their resources, but when patients and their doctors face care delays—or when they give up and abandon necessary care—the result can increase overall costs when worsening health conditions force patients to seek urgent or emergency treatment. Our patients are caught in the middle, twisting in the wind, while physicians fight for them, often with fax machines as our only available weapon.

The harm is not anecdotal. New survey data published by the AMA (PDF) this week bolsters our ongoing advocacy against onerous prior authorization processes that undermine the expertise of physicians by delaying or denying treatment plans, burden their practices with administrative hassles, and too often lead to avoidable health consequences for patients.

Nearly one in four physicians surveyed said prior authorization led to a serious adverse event for a patient in their care, according to the AMA’s survey of 1,000 physicians practicing in a broad range of settings nationwide. More than three-fourths of respondents said prior authorization can lead to patients abandoning treatment, while more than one-third reported that criteria used in making authorization decisions are rarely or never evidence-based.

Alarmingly, over nine in ten physicians reported that prior authorization negatively affects clinical outcomes for their patients. Additional consequences of prior authorization include greater physician burnout, reduced employee productivity, and significant costs incurred across the entire health care system.

Members of the AMA House of Delegates are keenly aware of the need to reform prior authorization, and adopted new policies to bring greater prior authorization transparency and accountability on the part of payers during their Annual Meeting earlier this month. The new policies underpin AMA advocacy to ensure insurers provide detailed explanations to both physicians and patients whenever they issue a denial, and to secure increased legal accountability for health insurers when their prior authorization procedures harm patients by interfering with medically necessary care.

As an otolaryngologist—an ear, nose and throat physician—in private practice in Louisville, Kentucky, I know firsthand that the lack of transparency in the denial process is one of the most frustrating aspects of modern medicine. I sit down with a patient, listen to their history, do a thorough exam, review imaging studies and then together we decide on a treatment plan. But then I have to get approval from an insurance company representative who has never seen my patient and who typically isn’t even a physician. Never mind an otolaryngologist who could best understand the prescribed course of treatment; it’s rare the person on the other line can even pronounce otolaryngology.

Recently I saw a patient with a tumor growing in the sinus next to her eye. She understood she needed surgery to remove the tumor, but her insurance company denied authorization for the surgery because she had not tried an antibiotic and a nasal spray—neither of which was going to cure the tumor. After a phone call to the medical director, the surgery was approved, but imagine the stress for her, when she received a letter from her insurer saying that the surgery was “not medically necessary.” That’s just wrong, and our patients deserve better.

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The fact that payers keep this process opaque and overly complex is no accident. A majority of physicians in the AMA survey said it is difficult to determine whether a particular prescription medication or medical service even requires prior authorization in the first place. Denials are issued without explanation or justification, without information on how the denial can be appealed, and with no guidance whatsoever on alternative treatment options. Physicians and their patients are left in the dark, with adverse outcomes too often the result.

Causing such harm should bear a price. As a result of newly enacted policy, the AMA will support legal consequences for insurers when their prior authorization processes disrupt medically necessary care and lead to patient harms.

The good news is that we are seeing measurable progress in our efforts to fix prior authorization. The AMA is working with state medical associations nationwide to achieve prior authorization reforms using AMA model legislation and other resources.

At the federal level, the Centers for Medicare & Medicaid Services (CMS) issued a final rule earlier this year that will reduce patient care delays as well as the administrative burdens long shouldered by physicians by right-sizing the prior authorization process imposed on medical services and procedures by Medicare Advantage and other government-regulated plans.

As part of these reform measures, health plans will be required to offer electronic prior authorization technology that directly integrates with EHRs, significantly reducing unnecessary burden for physicians and resulting in an estimated $15 billion in practice savings over 10 years, according to the U.S. Department of Health and Human Services.

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Yet the AMA’s most recent survey data underscore that additional prior authorization reforms are needed, and the time for legislative action is now. An updated version of bipartisan legislation to streamline and standardize prior authorization procedures within Medicare Advantage—the Improving Seniors’ Timely Access to Care Act of 2024—is pending before Congress and would codify many elements of the CMS regulation, as well as empower the agency to take additional steps to prevent care delays and improve transparency.

This legislation, which came close to passage during the last Congress, enjoys widespread support in both parties and from more than 500 outside organizations, including the AMA and numerous state and national medical associations. I urge everyone to join the AMA’s efforts to pass these common-sense reforms by contacting your members of Congress and voicing your support for this newly reintroduced legislation.

Working together, we can protect patients and improve the health of our nation by removing the unnecessary and potentially devastating impediments posed by unduly onerous prior authorization policies.