Sustainability

1 in 4 doctors say prior authorization has led to a serious adverse event

It just keeps getting worse. That’s a major finding of an AMA survey of 1,000 practicing physicians who were asked about the impact prior authorization (PA) is having on their ability to help their patients. 

More than nine in 10 respondents said PA had a significant or somewhat negative clinical impact, with 28 percent reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care. 

PA, a health plan cost-control process, restricts access to treatments, drugs and services. This process requires physicians to obtain approval prior to the delivery of the prescribed treatment, test or medical service in order to qualify for payment. 

Traditionally, health plans applied PA to newer, expensive services and medications. However, physicians report an increase in the volume of prior authorizations in recent years, to include requirements for drugs and services that are neither new nor costly.  

The vast majority of physicians (86 percent) described the administrative burden associated with prior authorization as “high or extremely high,” and 88 percent said the burden has gone up in the last five years. 

“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said AMA Board of Trustees Chair Jack Resneck Jr., MD. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.” 

“The AMA is committed to attacking the dysfunction in health care by removing the obstacles and burdens that interfere with patient care,” Dr. Resneck added. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely and affordable care, while reducing administrative burdens that pull physicians away from patient care.” 

The AMA offers prior-authorization reform resources that allow physicians to make a difference with effective advocacy tools, including model legislation and an up-to-date list of state laws governing prior authorization.  

Share  your story with the AMA about PA’s impact on your practice and your patients to help #FixPriorAuth. Visit FixPriorAuth.org to learn more.

Related coverage

Why prior authorization was a white-hot issue in 2018

Other highlights of the AMA physician survey include that: 

  • 91 percent believe that PA delays patients’ access to care. 
  • 75 percent reported that PA can lead to patients abandoning their course of treatment. 

The AMA survey was conducted online in December 2018. Participants were physicians who practice in the United States, provide at least 20 hours of direct patient care and complete PAs during a typical week of practice. Forty percent of participants were primary care physicians, and 60 percent were in other specialties.  

Physicians’ views on the impact of care delays comes into focus when one considers the typical turnaround times they see from health plans.

In the AMA survey: 

  • 65 percent of physicians said they wait an average of at least one business day for a prior-authorization decision from a health plan. 
  • 26 percent reported waiting at least three days. 
  • 7 percent reported waiting an average of more than five days. 

Physicians in the survey reported processing an average 31 PAs per week, with this PA workload consuming 14.9 hours—nearly two business days—of physician and staff time. 

Additionally, 36 percent reported that their practice has staff who work exclusively on PA.  

In January 2017, the AMA with 16 other associations urged industry-wide improvements in prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles. 

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a consensus statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.