Health Insurance Industry Slow to Adopt Prior Authorization Reforms

Mar 12, 2019 at 12:30 pm by Staff



After a year of foot-dragging and opposition, insurers must make improvements to prevent patient harm


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 r
ecurring 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.

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.

Sections: Business/Technology