Sustainability

5 changes to fix prior authorization that are well overdue

The unconstrained expansion of prior authorization (PA) requirements has created a challenging and exhausting burden for patients and physicians. According to one report, PA leads to 37% of prescriptions initially rejected at the pharmacy being left there, abandoned by discouraged patients.

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PA implementation for drugs used to treat diabetes, depression, schizophrenia and bipolar disorder has even been linked to higher net costs along with worsening disease status and increased hospitalizations. That’s according to research cited by Immediate Past AMA Board Chair Jack Resneck Jr., MD, in his JAMA Viewpoint, “Refocus Medication Prior Authorization on Its intended Purpose.”

Prior authorization is a health plan utilization-management or cost-control process that requires physicians to get approval before delivery of a prescribed treatment, test or medical service in order to qualify for payment. The AMA offers prior authorization resources to support reform, improve practice efficiency and provide data to highlight the need for change.

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Steps to right-size prior auth

In his article, Dr. Resneck wrote that PA was originally used to screen for the appropriateness of hospitalizations and high-cost procedures, but then its use spread into coverage of new prescription medications and is now often required even for decades-old generic drugs with no obvious lower-cost alternatives.

Dr. Resneck discussed prior authorization and his manuscript in an audio interview with JAMA Editor-in-Chief Howard Bauchner, MD, who began by noting that PA and poorly designed electronic health records “are the two issues that irritate clinicians more than virtually anything in modern medicine.”

Read about the eight prior authorization terms that drive every doctor crazy.

The AMA advocates that the following actions to be taken to right-size prior authorization:

  • Selectively apply PA only to outlier prescribers with histories of low approval rates, as opposed to broadly across all physicians.
  • Stop applying PA to services and medications that are usually ultimately approved or where PA offers little value.
  • Improve communication and transparency regarding the clinical basis, requirements and approval rates for PA requirements.
  • Protect continuity of care, especially for patients on treatment for chronic disease when they enroll in new plans or when plans change PA requirements.
  • Automate PA processes so that physicians can view requirements and submit requests seamlessly from their EHRs.

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Growing scrutiny among lawmakers, courts

Physicians are increasingly burdened by third-party interference that gets in the way of appropriate, high-quality patient care—by the government and by insurance companies. The AMA has been advocating for PA relief at both the federal and state levels on both the legislative and regulatory fronts. This advocacy may soon extend into the courts.

“I believe interference in the form of prior authorization, step therapy and coverage denial will face increasing legal scrutiny,” said Brian D. Vandenberg, senior vice president and general counsel at the AMA, in a recent interview. “I also expect that issues impacting access to care will trend in 2020.”

Step therapy, sometimes called “fail first” therapy, is another form of utilization management that requires patients to first try and fail lower-cost tests, drugs or other treatments before moving on to higher-cost options.

The AMA Advocacy Resource Center secured victory in 2019 on utilization-management legislation in 17 states despite facing strong opposition from insurers and their local trade associations. Learn more about how prior authorization fixes are happening at the state level.

Bipartisan legislation, the Improving Seniors’ Timely Access to Care Act of 2019 (H.R. 3107), has been introduced in Congress. Use this form at the AMA’s FixPriorAuth.org website to ask your U.S. representative to support the legislation.

“There are a lot of levers we can pull to try and get improvement,” Dr. Resneck said in the JAMA interview.

He noted that physicians first attempted to work with health plans and other stakeholders to find some common ground.

This effort led to the development of a consensus statement on how to improve the PA process, but health plans unfortunately “haven’t advanced the ball on this,” Dr. Resneck said. Read more about why insurers’ progress on fixing prior authorization has been disappointingly slow.

In closing the JAMA interview, Dr. Resneck said that he’s invited several health plan officials to come and observe the daily burden his practice faces getting even generic medications approved for his patients, including appeals and arguments “with someone who has never heard of the disease I’m trying to treat” about why he wants to prescribe drug X or drug Y for a patient who needs it.

No one has yet taken him up on the invitation.