Prior Authorization

As COVID-19 peaked, prior authorization’s harmful burdens continued

Kevin B. O'Reilly , Senior News Editor

What’s the news: Nearly 70% of physicians report that health plans either never relaxed their prior authorization requirements to help ease burdens during the pandemic, or the payers did so temporarily before reverting to business as usual.

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The discouraging finding is among the many included in the AMA’s most recent prior authorization physician survey, which was conducted at the height of the COVID-19 pandemic in December 2020 and released this month.

“As the COVID-19 pandemic began in early 2020, some commercial health insurers temporarily relaxed prior authorization requirements to reduce administrative burdens and support rapid patient access to needed drugs, tests and treatments,” said AMA President Susan R. Bailey, MD. “By the end of 2020, as the U.S. health system was strained with record numbers of new COVID-19 cases per week, the AMA found that most physicians were facing strict authorization hurdles that delayed patients’ access to needed care.”

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Why it’s important: The weekly prior authorization workload for a single physician doesn’t just gobble up an average of two business days of physician and staff time, as the survey shows. The process also negatively affects patient care, with 94% of doctors reporting care delays while waiting for health insurers to authorize necessary care, and 79% saying patients abandon treatment due to authorization struggles with health insurers.

“Delayed and disrupted treatment due to an archaic prior authorization process can have life-or-death consequences for patients, especially during a public health emergency,” said Dr. Bailey. “This hard- learned lesson from the current crisis must guide a reexamination of administrative burdens imposed by health insurers, often without any justification.”

Indeed, 90% of physicians reported that prior authorization requirements have a negative effect on patient clinical outcomes, with 30% saying the requirements have led to a serious adverse event for a patient in their care. More specifically, prior authorization requirements led to the following repercussions for patients:

  • Patient hospitalization—reported by 21% of physicians.
  • Life-threatening event or intervention to prevent permanent impairment or damage—reported by 18% of physicians.
  • Disability or permanent bodily damage, congenital anomaly, birth defect or death—reported by 9% of physicians.

Meanwhile, only 15% of physicians reported that prior authorization criteria were often or always based on evidence-based medicine.

The findings of the AMA survey illustrate a critical need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery. The AMA has taken a leading role in advocating for prior authorization reforms and convening key industry stakeholders to develop a roadmap for improving the prior authorization process.

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Learn more: In 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a consensus statement outlining a shared commitment to improving five key areas associated with the prior authorization process. However, health plans have made little progress in the last three years toward implementing improvements in each of the five areas outlined in the consensus statement.

Through research, collaborations, advocacy and leadership, the AMA is working to right-size prior authorization programs so that physicians can focus on patients rather than paperwork. Patients can share their own personal experiences with prior authorization at