More than 90% of physicians say prior authorization (PA) has a negative impact on patient care, according to new survey data from the AMA and the Illinois State Medical Society (ISMS), and the administrative burden PA creates keeps growing—even though the health insurance industry made a commitment more than two years ago to streamline the process.

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PA is a health plan utilization-management or cost-control process that requires physicians to obtain approval before a prescribed treatment, test or medical service qualifies for payment. The AMA has been advocating for PA reform and supporting legislative efforts to do so at the federal and state levels.

PA prevents patients from receiving the care they need—causing treatment delays, worse patient outcomes, higher overall costs for medical care and physician burnout. This would be bad enough under normal circumstances, but in the face of the COVID-19 pandemic, delaying necessary patient care is even more harmful than before. 

“With the current pandemic, it is more important than ever to end the insurers’ ability to delay care, second-guess clinical decision-making, and intrude in the patient-physician relationship,” said ISMS President Robert W. Panton, MD.

ISMS worked to get the proposed Prior Authorization Reform Act introduced in both chambers of the Illinois General Assembly this year.

The bill limits how long a PA review can take and calls for services to be automatically deemed as authorized if an insurance company fails to comply with these timelines. The bill also would make PAs valid for 15 months or, in the case of long-term treatments for chronic conditions, the PA will remain valid for the length of the treatment.

The legislation would ensure continuity of care and require transparency and appropriate peer-to-peer review, according to the ISMS.

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“These unnecessary and time-consuming prior authorizations raise obstacles for patients, complicate health care and waste health professionals’ time with bureaucratic paperwork,” Illinois House Majority Leader Gregory Harris, the Illinois House Majority Leader, said when the measure was introduced. “This bill will knock down those barriers for patients.”

The ISMS has teamed with the state chapters of national medical specialty societies, hospital and nurse associations, the Illinois Association for Behavioral Health, and organizations such as the Arthritis Foundation and Cancer Action Network to form the Your Care Can’t Wait coalition.

The Your Care Can’t Wait coalition website provides information for and stories from patients and health care professionals. This includes physician survey results and comments on the most frustrating aspects of prior authorization. These include:

  • Insulin prescriptions for diabetic patients requiring prior approval.
  • PA being required to lower the dosage of a medication that was already approved.
  • PA suddenly being required for medications that the patient has been taking for years with good results.
  • PA being required for generic medications to treat asthma, psoriasis, and many other common conditions.

Similar activities are underway elsewhere. For example, the Michigan State Medical Society, as part of the Health Can’t Wait Coalition, has been working to streamline PA in its state and protect patients from unnecessary barriers to care. Most recently MSMS supported S.B. 612, which would introduce new transparency and clinical validity requirements.

“Providing quality care to patients is the top priority of physicians, but waiting for a health plan authorization can delay and disrupt patient-centric care with a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles,” said AMA President Susan R. Bailey, MD.

Dr. Bailey noted that the AMA worked with the health insurance industry to develop a consensus statement on PA reforms, which included industry commitments to improve transparency and move toward automating the PA process, protect continuity of care, and to regularly review which services, drugs or therapies no longer warrant PA due to minimal variation in utilization  or low PA denial rates.

Related coverage

Prior auth survey findings underscore need for legislative action

Insurers’ progress on fixing PA, however, has been disappointingly slow.

“More than two and a half years after agreeing with physicians on needed improvements, the health insurance industry has made little progress toward those goals,” Dr. Bailey said. “Failure of health insurers to achieve agreed-upon improvements illustrates a clear opportunity for Illinois lawmakers to rein-in prior authorization requirements that adversely affect patient health.”

The AMA offers prior-authorization resources to support reform, improve practice efficiency and provide data highlighting the need for change. Learn more at the AMA’s website FixPriorAuth.org.

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