Physicians know all too well the countless hours and frustrations spent dealing with insurance companies’ prior authorization practices, and the AMA and other physician organizations have been fighting to fix the system.
Patients and physicians saw a significant victory in January with the Centers for Medicare & Medicaid Services (CMS) announcing a final rule that will save physician practices about $15 billion over a decade by cutting patient-care delays and electronically streamlining the prior authorization process for physicians. But there is still more work to do on the state and federal level.
Patient advocacy groups—groups traditionally focused on research and awareness for a specific disease, advocacy and connecting and empowering patients—have increasingly joined the effort to effect meaningful reforms for patients and physicians. These organizations, too, are collecting data and anecdotes to advocate for patients who have been sharing grievances of how prior authorization is harming their access to care.
“Patients are not always looked at as equal players in this, but they are. CMS and others often seemed surprised that patients want to be informed and involved. There is not enough understanding of how much time patients put into managing their care,” Anna Hyde, vice president of advocacy and access for the Arthritis Foundation, said in an interview with the AMA.
She and a leader from the Leukemia and Lymphoma Society spoke at the 2024 AMA State Advocacy Summit to detail why they are getting involved in this advocacy fight and sharing patient stories and prior authorization data.
At every level, patients’ voices are critical to turning the tide on the time-wasting, care-delaying payer practice of prior authorization. Nine states ultimately passed some form of prior authorization reform legislation in 2023, and nearly 30 states have prior authorization bills before their legislatures so far this year.
Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.
Data, stories emerge
After hearing anecdotal stories about patient experiences with prior authorization, patient advocacy organizations set out to find more data and details to better quantify what is going on.
In putting together a white paper about patients’ prior authorization experience, the Leukemia and Lymphoma Society put a call out to their patient community for stories. Lucy Culp, the organization’s executive director of state government affairs, shared a Minnesota woman’s story of experiencing numerous denials through the diagnostic period only to then have her insurance company tell her that they would need to review and approve every single one of her 12 prescribed chemotherapy visits rather than approving the entire course of treatment for the woman, named Kelly.
“You can just imagine the stress and anxiety that Kelly was feeling at the idea that every single time she might be told no and have to stop treatment or face thousands of dollars in medical bills,” Culp said.
Prior authorization has repeatedly come up as an issue for arthritis patients over the years. To dig deeper into patients’ experiences, the Arthritis Foundation surveyed more than 3,000 patients and held two focus group sessions in 2023. Among their findings:
- 43% of patients went through prior authorization the first time a medication was prescribed.
- 37% of patients go through prior authorization every plan year.
- Three days was the average wait time for prior authorization approval, but 31% of respondents said they had waited more than a week.
- 88% of the time, approvals were granted.
- 43% appealed denials and were not successful; 28% appealed and did succeed; 28% didn’t bother appealing.
- 55% used different medication or didn’t use medication at all when the appeal was not successful.
One arthritis patient described prior authorization as a “hurricane,” Hyde said. The patient stockpiled medications to avoid treatment disruptions in anticipation of another lengthy and cumbersome prior authorization process.
This data is very consistent with the AMA’s own survey of physicians (PDF), which found that 80% of doctors said that prior authorization at least sometimes led patients to abandon treatment. It is further supported by the 2023 research findings presented by another panelist, Kate Pestaina, director of the Program on Patient and Consumer Protections at KFF, formerly known as the Kaiser Family Foundation.