How prior authorization harms patients and drives physician burnout with Marilyn Heine, MD

. 9 MIN READ

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

Prior authorization plays a major role in physician burnout. Joining to break down the big impact of this administrative burden is Marilyn Heine, MD, a member of the AMA Board of Trustees and clinical assistant professor in the Department of Medicine at Drexel University College of Medicine. Dr. Heine discusses the rise of prior authorization and the growing physician shortage, and shares her own prior authorization horror stories. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Marilyn Heine, MD, member, AMA Board of Trustees and clinical assistant professor, Department of Medicine, Drexel University College of Medicine

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Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about how prior authorization and physician burnout are connected. Joining us to discuss this is Dr. Marilyn Heine, a member of the AMA board of trustees and clinical assistant professor in the Department of Medicine at Drexel University College of Medicine. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Heine, welcome.

Dr. Heine: Thank you, Todd. Great to be here.

Unger: Well, we know that any kind of administrative burden plays a role in burnout, but let's talk about something specific and the impact of prior authorization. Tell us a little bit about what you're learning in terms of that connection.

Dr. Heine: Well, Todd, prior authorization has a huge impact. And we don't need to look far to find evidence of that. In a recent survey, around 80% of physicians said that prior authorization requirements rose significantly or somewhat for both prescription medications and medical services over the past five years. And during that time, policymakers and the general public became more aware of just how disruptive prior authorization can be. So to see most physicians say that requirements are increasing is really concerning.

However, the issue isn't just the volume of requirements and the time it takes to complete them. Physicians also spend time simply to figure out if they need prior authorization. In that same survey, over 60% of physicians said it's difficult to determine whether a prescription or medical service requires prior authorization. So that amounts to even more time wasted.

What brings physicians joy is caring for patients. And overused prior authorization directly gets in the way of that.

Unger: Absolutely. And the statistics are pretty alarming. And I'm so interested the way that you pointed out it's not just the time of getting the authorization, it is all of that time and even figuring out whether it needs to be done in the first place. So a lot of wasted time that's taking away from patient care. And it's stressful enough that physicians have to spend so much time on paperwork instead of patient care. Unfortunately, we do know that prior authorization also complicates patient care. Dr. Heine, tell us a little bit more the impact that that's having right now.

Dr. Heine: Well, on the time issue, as an example, a neurologist colleague said that he was on the phone with the patient's insurer for over an hour to obtain prior authorization for prednisone, an inexpensive and very old medication. The patient had multiple sclerosis and required the medication to function. And often, my colleagues and I need to step away from a patient whom we're seeing in order to go through a peer-to-peer appeal to provide prior authorization for another patient's care for something important for them. So prior authorization hurts all patients, as it not only delays appointments, but it also pulls physicians away from patient care to talk to insurers.

Unger: And that example that you gave of prednisone just doesn't seem to make sense, does it? And I'm almost afraid to ask. And I know that everybody I talk to about this topic has their own stories about how this impacts them firsthand. Tell us a little bit about how prior auth affects you and your colleagues.

Dr. Heine: Yeah, so I'll just give an overall. Prior authorization isn't just a bureaucratic burden. It regularly interrupts the delivery of care, and in some cases, actively puts patients in danger. So let's go back to that AMA survey. A whopping 89% of physicians said prior authorization sometimes, often, or always leads to missed doses of medication, interruptions of chronic treatment, or otherwise interferes with the continuity of care. And if that weren't bad enough, 33% said that prior authorization has led to a serious adverse event, including hospitalization, permanent impairment or death for a patient in their care.

This is unacceptable and it takes a real psychological toll on physicians. We often hear the phrase "moral injury" associated with the impact of prior authorization on physicians and it's a spot-on description. So between the time spent on prior authorization and the emotional toll of knowing this process is harming our patients, that's when we get the high levels of burnout that we're seeing today. And I can provide you with several cases as examples if you would like.

Unger: Well, why don't we start with one from your personal experience?

Dr. Heine: Yeah, so Todd, here are just three brief examples. A colleague cared for a patient who died in the intensive care unit due to a massive blood clot in her lung. She had a history of a blood clot in her leg and was prescribed a blood thinner but had not received this due to prior authorization. Another colleague's cancer patient required chemotherapy and he prescribed a protective factor to ensure that her white blood cell count would not fall. But since that protection was not approved, the patient's white blood cell count dropped. She developed a fever with infection and required hospitalization.

This side effect could have been prevented if the physician had not been interfered with by the insurer. And another colleague's infant daughter was diagnosed with brain cancer and her vital care was delayed, awaiting prior authorization.

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Unger: These stories are—they're horrifying and moving and are such great examples of the harm that can result for patients due to prior auth. Dr. Heine, you mentioned the term "moral injury" in connection with physician burnout. Another huge problem here is that we are in a tough situation just with the number of physicians. There is a physician shortage. And these kinds of burdens are causing physicians to stop practicing entirely. That is not something we can afford. If things don't change, what does this mean for patients?

Dr. Heine: Well, Todd, the physician shortage is already having serious implications for patients and medicine as a whole. In another AMA survey, one in five physicians reported that they plan to leave their current practice within two years, and about one in three physicians intended to reduce their work hours in the coming 12 months. Those statistics reflect what I've been hearing from my colleagues for years. They say they're cutting back on their hours, changing their practice or retiring early, often because of administrative burdens which are largely driven by prior authorization.

This is a major concern. Unless urgent action is taken to address these burdens, the physician shortage is going to get worse. That means longer wait times for patients, less access to high-quality physician-led care, and ultimately, worse outcomes for patients.

Unger: And that is a terrible cycle. And because of the enormity of this issue, fixing prior authorization is one of the key pillars of the AMA Recovery Plan for America's Physicians. And while we've made progress this year, there's still a lot more to do. Dr. Heine, how can physicians continue to help us make the case for change here?

Dr. Heine: Yeah, so Todd, there are actually a few positive developments so far this year. And we'll talk about the role that physicians can take in further advancing that. So just this summer, the House Ways and Means Committee advanced provisions that would bring much-needed prior authorization reforms within Medicare Advantage. Congress sent a bipartisan, bicameral letter to the Centers for Medicare and Medicaid Services urging finalization of a federal regulation that would overhaul Medicare Advantage prior authorization requirements. And the AMA helped spearhead support for that letter to ensure a robust number of members of Congress co-sign that important communication. And states are advancing prior authorization reforms.

But as you know, there's still so much more that insurance companies need to do. They have to limit their use of prior authorization and streamline the process. And that's really just the beginning, though. Insurers must be more transparent. They must be timelier in their responses and implement gold carding. So how do we make that happen? Like with all the priorities in the recovery plan, we need to keep the issue of prior authorization front and center. Physicians should continue to speak out and share their personal experiences. Physicians can contact their legislators, post on social media, tell their stories on fixpriorauth.org, and engage their patients to do likewise.

Unger: Absolutely. And I just want to emphasize something that Dr. Heine said there—it's about telling your stories. They're so persuasive. We've heard from our advocacy team too that getting those stories to your Congresspeople—very, very important. And Dr. Heine, I just want to say thank you for sharing your own stories and for continuing to speak out on this issue. It's so important.

That wraps up today's episode. To learn more about the AMA's work to fix prior authorization, visit ama-assn.org/recovery. We'll be back soon with another AMA Update. You can subscribe to new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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