CHICAGO — Waiting for health plans to authorize necessary medical treatment is hazardous to patients’ health. Despite potentially harmful consequences of delayed or disrupted care, most health plans are not making meaningful progress on reforming the cumbersome prior authorization process they increasingly impose on patient-centric care, according to physician survey results released today by the American Medical Association (AMA).
“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” said AMA President Barbara L. McAneny, M.D. “In previously released AMA survey results, more than a quarter of physicians reported that insurers’ extended business decision-making process led to serious adverse events for waiting patients, such as a hospitalization or disability. The time is now to fix prior authorization.”
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a joint consensus statement that outlined five key areas for industry-wide improvements to prior authorization processes and patient-centered care. The shared commitment was signed by two trade organizations representing payers: America's Health Insurance Plans and the Blue Cross Blue Shield Association.
The newly released AMA survey results gauge the progress that health plans have made toward implementing each of the five areas of prior authorization reform outlined in the consensus statement.
- Selectively apply requirements.
Insurers should exempt physicians with prescribing patterns that meet evidence-based guidelines or high approval rates from prior authorization, according to the consensus statement. However, only eight percent of physicians report contracting with health plans that offer programs that exempt providers from prior authorization.
- Adjust the volume of requirements.
Insurers should regularly review drugs and services under prior authorization and remove those that show "low variation in utilization or low prior authorization denial rates," according to the consensus statement. However, most physicians (88 percent) report the number of drugs requiring prior authorization has increased. An almost equal physician majority (86 percent) report the number of 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. However, almost seven in 10 physicians (69 percent) report that it is difficult to determine whether a drug or 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. However, most physicians (85 percent) report 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. However, physicians still report phone and fax as the most commonly used methods for completing prior authorization requirements. Moreover, only 21 percent of physicians report that their electronic health record system offers electronic prior authorization for prescription medications.
Growing concern that strict utilization management protocols prioritize insurance business decisions over access to timely, optimal care has led to the introduction of 84 patient protection bills in 32 states this year. Nearly all these bills attempt to fix something broken in prior authorization programs. Some bills would remove prior authorization and speed access to lifesaving treatments—like medications to treat opioid use disorders.
In the last year, insurers in some states, like Pennsylvania and Vermont, have worked constructively with the medical community to remove prior authorization requirements for the treatment of opioid use disorder. This cooperation stands in stark contrast to the situations in Kentucky and Montana, where insurers have actively opposed removing prior authorization for treatment of opioid use disorder despite the human costs resulting from delayed or disrupted access to treatment.
“There is no reason for insurers to use prior authorization for medications to treat opioid use disorders when patients’ lives hang in the balance,” said Dr. McAneny. “The AMA urges all health insurers to join with the medical community to enact vital legislation that is an important step in reversing the opioid epidemic.”
To further support prior authorization reform, the AMA is also inviting the public to get involved. New videos have been produced to illustrate the crippling delays and dysfunction that prior authorizations introduce into health care, and the needless harm that can result. Patients can share their own personal experiences with prior authorization and add their voices to reform efforts by signing a patient petition at FixPriorAuth.org.
The AMA continues 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 premier national organization providing timely, essential resources to empower physicians, residents and medical students to succeed at every phase of their medical lives. Physicians have entrusted the AMA to advance the art and science of medicine and the betterment of public health on behalf of patients for more than 170 years.