CHICAGO — Despite mounting evidence that insurer-imposed authorizations for drugs and medical services can be a hazardous and burdensome administrative obstacle to patient-centered care, the health insurer industry continues to show apathetic or ineffectual follow-through on mutually accepted reforms, according to new physician survey results (PDF) released by the American Medical Association (AMA).
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health insurers signed a consensus statement (PDF) outlining a shared commitment to five key reforms for the prior authorization process. Taken together, the five reforms promote safe, timely, and affordable access to evidence-based care for patients; enhanced efficiency; and reduced administrative burdens.
However, findings from the AMA physician survey conducted in December 2021 call into question whether the health insurance industry can be relied upon to voluntarily expedite comprehensive reform to the cumbersome prior authorization process that delays and disrupts patient-centric care.
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” said AMA President Gerald E. Harmon, M.D. “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”
The newly released AMA survey examines the experiences of more than 1,000 practicing physicians with each of the five prior authorization reforms in the consensus statement and illustrates that the goal of comprehensive reform is far from complete.
Selectively apply requirements
Prior authorization requirements should be selectively applied to physicians based on demonstrated adherence to evidence-based guidelines and quality measures, according to the consensus statement. Survey results show fewer than one out of ten physicians (9%) contracted with health plans that offer programs that selectively apply prior authorization requirements.
Adjust the volume of requirements
The list of drugs and services that require prior authorization should be regularly reviewed by insurers to remove items that show "low variation in utilization or low prior authorization denial rates," according to the consensus statement. Most physicians (84%) reported the number of drugs requiring prior authorization has increased. An equal majority of physicians (84%) reported the number of medical services needing prior authorization has grown.
Make rules clear and accessible
Insurers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes," the consensus statement reads. Almost two-thirds of physicians (65%) reported it is difficult to determine whether a drug requires prior authorization. Slightly fewer physicians (62%) reported it is difficult to determine whether a medical service requires prior authorization.
Support continuity of patient care
Insurers should “minimize disruptions in needed treatment,” including “minimizing repetitive prior authorization requirements,” as stated in the consensus statement. An overwhelming majority of physicians (88%) reported that prior authorization interferes with continuity of care.
Accelerate the use of automation
Efforts should be made to speed the adoption of existing national standards for electronic transactions for prior authorizations, according to the consensus statement. Only about one out of four (26%) physicians reported that their electronic health record system offers electronic prior authorization for prescription medications.
Given the health insurance industry’s lack of progress toward voluntarily expediting comprehensive prior authorization reform outlined in the consensus statement, the AMA and other physician organizations are calling on Congress to remedy the problem. The Improving Seniors’ Timely Access to Care Act (HR 3173 / S 3018) takes direct aim at the insurance industry’s foot-dragging and would codify much of the consensus statement.
To further support prior authorization reform, the AMA also invites the public to get involved. Patients can share their own personal experiences with prior authorization and add their voices to legislative reform efforts by signing a petition and messaging Congress at FixPriorAuth.org.
The AMA continues to work on every front to reform prior authorization. Through our research, collaborations, advocacy and leadership, the AMA is working to make the patient‐physician relationship more valued than paperwork by right-sizing prior authorization programs.
Robert J. Mills
ph: (312) 464-5970
About the American Medical Association
The American Medical Association is the physicians’ powerful ally in patient care. As the only medical association that convenes 190+ state and specialty medical societies and other critical stakeholders, the AMA represents physicians with a unified voice to all key players in health care. The AMA leverages its strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises and, driving the future of medicine to tackle the biggest challenges in health care.