Anecdotes about the patient care delays and practice burdens caused by health plans' onerous prior authorization (PA) requirements are common across organized medicine, but quantitative data to substantiate these stories has been limited until recently. Results from the AMA's new PA physician survey (PDF) provide strong evidence of the significant impact this burdensome process can have on both patients and physician practices.
Results from the December 2017 survey of 1,000 practicing physicians clearly show the negative effect that PA can have on timely patient care. Among surveyed physicians, 64 percent reported waiting at least one day for PA decisions from health plans, while 30 percent reported waiting at least three business days.
These wait times translate into patient care delays, with 92 percent of physicians saying that PA sometimes, often or always delays access to necessary care. These delays may have more serious implications for patients, as 78 percent of physicians reported that PA can lead to treatment abandonment. Moreover, an overwhelmingly majority (92 percent) of physicians indicated that PA can have a negative impact on patient clinical outcomes.
Beyond these concerning statistics reflecting negative consequences for patients, the survey also addressed the burdens imposed on physicians and their staff by PA. The survey results show that practices complete an average of 29.1 PAs per week per physician, with this PA workload requiring 14.6 hours—nearly two business days—of physician and staff time. Not surprisingly, 84 percent of physicians characterized PA-related burdens as high or extremely high. PA hassles also have been growing over time, with 86 percent of physicians reporting that PA burdens have increased over the past five years.
This data reinforces the need for strong advocacy efforts on PA reform. The AMA has undertaken a major campaign to urge health plans to "right-size" PA programs. In January 2017, the AMA and a coalition of 16 other organizations representing physicians, hospitals, medical groups, pharmacists and patients released a set of 21 Prior Authorization and Utilization Management Reform Principles (PDF). These principles, which have been formally supported by over 100 additional provider and patient groups, spurred conversations with health plans about the need for significant reform in PA programs.
As a result of those discussions, the AMA, along with the American Hospital Association, America's Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association, released the Consensus Statement on Improving the Prior Authorization Process (PDF) in January 2018. This document reflects agreement between provider and health plan organizations to pursue PA reform in several key areas, including reduction in the overall volume of PAs, improved transparency and communication, protection of continuity of care, and automation to increase process efficiency.
State legislative efforts also play a critical role in the AMA's campaign to improve PA processes, and the AMA is working with state and specialty societies to enact legislation. The AMA offers model legislation (PDF) that continues to serve as the basis for many of the state bills and provides resources and support for these efforts. This year alone, more than twenty states are addressing utilization management reform in their legislatures.
The AMA also offers educational resources to help physicians and their staff reduce the manual burdens associated with PA and transition to automated processes. A new, three-part educational video series describes the current impact of the PA workload on physician practices, demonstrates the workflow improvements and other advantages of implementing pharmacy electronic PA transactions that integrate with electronic health record systems, and offers tips on how practices can start using this technology. Access these videos, along with additional resources and information about the AMA's advocacy efforts on PA reform, by visiting ama-assn.org/prior-auth.
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