Prior Authorization

Prior authorization needs fixing. How it’s happening in the states.

Andis Robeznieks , Senior News Writer

The hundreds of physicians and state medical society executives and staffers attending the AMA State Advocacy Summit heard about how patient care is delayed by prior authorization (PA), a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

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Physician legislators also told of how their states passed PA reforms.

The AMA offers prior authorization resources—such as a model bill—to support reform, improve practice efficiency and provide data to highlight the need for change. You can learn more, and share your story, at the AMA’s website or on social media by using the #FixPriorAuth hashtag. 

Jack Resneck Jr., MD, the immediate past chair of the AMA Board of Trustees, shared the results of an AMA prior authorization survey that found that the average physician must process 31 PA requests a week, which chew up almost two business days of practice staff time.

“We also know it doesn’t just burden us, it clearly hurts our patients, obviously mainly through treatment delays,” said Dr. Resneck, a health policy expert and professor of dermatology at the University of California, San Francisco. “Over one-third of the time, patients throw up their hands, give up and abandon treatment.”

He added that the AMA is “aggressively fighting” for the PA process to be built into an electronic health record’s (EHR’s) prescribing workflow, so physicians know in advance which drugs or treatments payers will subject to the PA process.

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Dr. Resneck also noted that the goal is to “right-size” the process and bring it back to its original focus to identify outliers in spending and validate the use of new or more expensive treatments. He echoed these messages in a JAMA Viewpoint column, published online this week, entitled “Refocusing Medication Prior Authorization on Its Intended Purpose.”

“Under the expanded use of medication prior authorization, both physicians and patients are experiencing a challenging and often exhausting burden that has raised calls for prior authorization to be rightsized and simplified,” Dr. Resneck wrote. He proposed three reasonable solutions:

  • Focus PA on its intended purpose and eliminate it for medications with very low final denial rates.
  • Protect continuity of care for patients who are stable with chronic treatment.
  • Promote transparency, efficiency and fairness by allowing physicians and other prescribers to view in their EHRs—while face-to-face with their patient—the formulary status, PA requirements, and cost-sharing portion of the medication being considered or for any alternatives.

State reforms have been adopted in Kentucky and Maryland.

Kentucky’s new law took effect Jan. 1, and requires that:

  • Physicians must receive responses on PA requests within 24 hours for urgent services and within five days for nonurgent services.
  • Prescriptions for chronic-condition maintenance drugs be valid for one year, and any change in dosage during this period will be covered.
  • Insurers’ PA procedures,  as well as a complete list of services requiring PA, be posted online. Insurer PA reviewers be licensed physicians and, when possible, of the same specialty as the requesting physician.

Maryland’s new PA-reform law requires:

  • Insurance carriers to honor a PA from a previous entity for at least the first 30 days of beneficiaries’ prescription drug-benefit coverage.
  • That a previous PA be honored when a beneficiary moves between health plans within the same carrier or when there is a dosage change.
  • At least 30 days’ notice be given to patients and their health care provider before implementing a PA change.

The Maryland bill was championed by General Assembly Delegate Terri Hill, MD, a plastic surgeon. She said the legislative strategy was to focus on reducing PA for urgent needs and repeated prescriptions for chronic conditions.

“The idea is to make it simpler for patients, make it simpler for pharmacists—who really have had it up to here as well,” she said at the State Advocacy Summit.

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The Kentucky bill was sponsored by state Sen. Ralph Alvarado, MD, an internist and pediatrician, who noted some provisions sought by the Kentucky Medical Association had to be abandoned to get the bill and its relief for patients with chronic conditions “across the finish line.”

Physician advocates must come across as offering a proactive solution rather than providing a reactive complaint, Dr. Alvarado advised. He added that physicians should recognize that patients are often more effective in influencing lawmakers than are doctors.

Anna Hyde, vice president for advocacy and access for the Arthritis Foundation, said her organization’s strategy when approaching policymakers is to pair a patient with a clinician. Patients tell how the problem affects their lives and clinicians explain the medical issues and clarify any questions around the solution being offered.

“We do nothing in isolation,” Hyde said. “I think it’s most powerful to have a patient and provider in the meeting together.”

Dr. Resneck also noted that another solution the AMA proposes is “gold carding,” where a physician or practice with high approval rates for PA requests doesn’t need to go through the process all the time—especially for medications that, ultimately, always get approved. He likened it to the Transportation Security Administration’s PreCheck program that allows airline travelers to get expedited security screening.

A consensus statement for PA reform developed with payers by the AMA and other organizations calls for “selective application” of PA based on “ordering/prescribing patterns that align with evidence-based guidelines and historically high prior authorization approval rates.” But payers are now pulling back from that promise, Dr. Resneck said.