Prior authorization (PA) continues to be a major barrier to patient care and a contributing factor in physician burnout. Physician practices complete an average of 31 prior authorizations a week per physician, with this workload consuming roughly 14.9 hours (almost two full business days) of physician and staff time. This is to say nothing of the impact on care for patients whose lives can be endangered by the unnecessary delay of treatment. Simply put, prior authorization is the overstepping of insurers into the clinical decision-making process, and the AMA is committed to fixing the problem by working with state legislators and medical societies to remove insurance company interference in the timely delivery of patient care.

The AMA released its 2018 Prior Authorization Physician Survey results earlier this year, and of the 1,000 practicing physicians surveyed:

  • 65% report waiting at least one business day for a prior authorization decision, and 26% reported waiting at least three business days
  • 91% report care delays associated with prior authorization
  • 75% report that prior authorization can lead to treatment abandonment
  • 91% report that prior authorization can have a negative impact on patient clinical outcomes
  • 86% of physicians say that prior authorization burdens are high or extremely high
  • 88% of physicians report that prior authorization burdens have increased over the last five years

But perhaps most concerning is that 28% of respondents reported prior authorization has led to a serious adverse event (e.g., death, hospitalization, disability) for a patient in their care.

Therefore, it is no surprise that there were nearly 85 bills in the state legislatures this year addressing utilization management, and in several states (e.g., CO, KY, MD, ME, MO, NM, TX, VA, WV), legislation was enacted despite strong opposition from insurers. The AMA has long supported these state legislative efforts with resources, including model legislation that addresses response times, automation, transparency, qualifications of reviewers and continuity of care, among other important reforms.

The opioid epidemic has made the need to fix prior authorization especially urgent, as patients with substance use disorders are often subjected to senseless denials and delays in care when prescribed medication-assisted treatment (MAT). These denials or delays often come at a critical moment when a patient who cannot quickly access MAT risks overdose and death. Thus far in 2019, at least 15 states have introduced bills to prevent prior authorization for MAT based on AMA model legislation.

Before 2019, only four states had legislation or other initiatives that removed prior authorization for MAT: MD, IL, AZ and PA. Thus, while the 2019 activity has been positive, payers in more than half the nation continue policies that delay and deny care to those seeking treatment for an opioid use disorder.

There has also been growing interest in prior authorization reform at the federal level. The Centers for Medicare & Medicaid Services (CMS) recently announced plans to address prior authorization under its Patients Over Paperwork initiative and have conducted listening sessions with the AMA, state medical associations and national medical specialty societies to gather information about prior authorization's impact on care delivery and practice resources.

In these discussions, the AMA and other organizations have stressed the lack of meaningful changes observed in prior authorization programs across commercial insurers, despite the release in early 2018 of the Consensus Statement on Improving the Prior Authorization Process (PDF), an important agreement between health care professional associations and national insurer trade organizations on the need for prior authorization reform. The AMA's Industry Checkup (PDF) illustrates the lack of progress on this issue. Given this stagnation, the AMA urges CMS to serve as a leader and model meaningful prior authorization reforms for commercial insurers—both to protect patients' health and reduce practice burdens—by developing a comprehensive strategy that addresses all areas of the Consensus Statement:

  • Selective application of prior authorization to only "outliers" (vs. bluntly across all physicians)
  • Review/adjustment of prior authorization lists to remove services/drugs that represent low-value prior authorizations
  • Transparency of prior authorization requirements and their clinical basis to patients and physicians
  • Protections of patient continuity of care
  • Automation to improve prior authorization transparency and process efficiency

The AMA is dedicated to stemming the tide of prior authorization and eliminating senseless delays to necessary patient care. Join the fight to fix prior authorization by visiting fixpriorauth.org and engaging with the AMA's grassroots campaign that unites physician and patient voices in a common call for change.

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